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Karwa ML, Naqvi AA, Betchen M, Puri AK. In-Hospital Triage. Crit Care Clin 2024; 40:533-548. [PMID: 38796226 DOI: 10.1016/j.ccc.2024.03.001] [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] [Indexed: 05/28/2024]
Abstract
The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.
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Affiliation(s)
- Manoj L Karwa
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Weiler Hospital, 4th Floor, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Ali Abbas Naqvi
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Melanie Betchen
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Ajay Kumar Puri
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
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Ramadurai D, Patel H, Peace S, Clapp JT, Hart JL. Integrating Social Determinants of Health in Critical Care. CHEST CRITICAL CARE 2024; 2:100057. [PMID: 39238802 PMCID: PMC11375804 DOI: 10.1016/j.chstcc.2024.100057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
BACKGROUND Social determinants of health (SDOHs) mediate outcomes of critical illness. Increasingly, professional organizations recommend screening for social risks. Yet, how clinicians should identify and then incorporate SDOHs into acute care practice is poorly defined. RESEARCH QUESTION How do medical ICU clinicians currently operationalize SDOHs within patient care, given that SDOHs are known to mediate outcomes of critical illness? STUDY DESIGN AND METHODS Using ethnographic methods, we observed clinical work rounds in three urban ICUs within a single academic health system to capture use of SDOHs during clinical care. Adults admitted to the medical ICU with respiratory failure were enrolled prospectively sequentially. Observers wrote field notes and narrative excerpts from rounding observations. We also reviewed electronic medical record documentation for up to 90 days after ICU admission. We then qualitatively coded and triangulated data using a constructivist grounded theory approach and the Centers for Disease Control and Prevention Healthy People SDOHs framework. RESULTS Sixty-six patients were enrolled and > 200 h of observation of clinical work rounds were included in the analysis. ICU clinicians infrequently integrated social structures of patients' lives into their discussions. Social structures were invoked most frequently when related to: (1) causes of acute respiratory failure, (2) decisions regarding life-sustaining therapies, and (3) transitions of care. Data about common SDOHs were not collected in any systematic way (eg, food and housing insecurity), and some SDOHs were discussed rarely or never (eg, access to education, discrimination, and incarceration). INTERPRETATION We found that clinicians do not incorporate many areas of known SDOHs into ICU rounds. Improvements in integration of SDOHs should leverage the multidisciplinary team, identifying who is best suited to collect information on SDOHs during different time points in critical illness. Next steps include clinician-focused, patient-focused, and caregiver-focused assessments of feasibility and acceptability of an ICU-based SDOHs assessment.
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Affiliation(s)
- Deepa Ramadurai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Philadelphia, PA
- Hospital of the University of Pennsylvania, the Palliative and Advanced Illness Research (PAIR) Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - Heta Patel
- Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | | | - Justin T Clapp
- Department of Medical Ethics and Health Policy, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Philadelphia, PA
- Department of Anesthesia and Critical Care, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Joanna L Hart
- Division of Pulmonary, Allergy, and Critical Care Medicine, Philadelphia, PA
- Department of Medical Ethics and Health Policy, Philadelphia, PA
- Hospital of the University of Pennsylvania, the Palliative and Advanced Illness Research (PAIR) Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Philadelphia, PA
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Myers LC, Lawson BL, Escobar GJ, Daly KA, Chen YFI, Dlott R, Lee C, Liu V. Evaluation of an outreach programme for patients with COVID-19 in an integrated healthcare delivery system: a retrospective cohort study. BMJ Open 2024; 14:e073622. [PMID: 38191255 PMCID: PMC10806839 DOI: 10.1136/bmjopen-2023-073622] [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: 03/14/2023] [Accepted: 11/30/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES In the first year of the COVID-19 pandemic, health systems implemented programmes to manage outpatients with COVID-19. The goal was to expedite patients' referral to acute care and prevent overcrowding of medical centres. We sought to evaluate the impact of such a programme, the COVID-19 Home Care Team (CHCT) programme. DESIGN Retrospective cohort. SETTING Kaiser Permanente Northern California. PARTICIPANTS Adult members before COVID-19 vaccine availability (1 February 2020-31 January 2021) with positive SARS-CoV-2 tests. INTERVENTION Virtual programme to track and treat patients with 'CHCT programme'. OUTCOMES The outcomes were (1) COVID-19-related emergency department visit, (2) COVID-19-related hospitalisation and (3) inpatient mortality or 30-day hospice referral. MEASURES We estimated the average effect comparing patients who were and were not treated by CHCT. We estimated propensity scores using an ensemble super learner (random forest, XGBoost, generalised additive model and multivariate adaptive regression splines) and augmented inverse probability weighting. RESULTS There were 98 585 patients with COVID-19. The majority were followed by CHCT (n=80 067, 81.2%). Patients followed by CHCT were older (mean age 43.9 vs 41.6 years, p<0.001) and more comorbid with COmorbidity Point Score, V.2, score ≥65 (1.7% vs 1.1%, p<0.001). Unadjusted analyses showed more COVID-19-related emergency department visits (9.5% vs 8.5%, p<0.001) and hospitalisations (3.9% vs 3.2%, p<0.001) in patients followed by CHCT but lower inpatient death or 30-day hospice referral (0.3% vs 0.5%, p<0.001). After weighting, there were higher rates of COVID-19-related emergency department visits (estimated intervention effect -0.8%, 95% CI -1.4% to -0.3%) and hospitalisation (-0.5%, 95% CI -0.9% to -0.1%) but lower inpatient mortality or 30-day hospice referral (-0.5%, 95% CI -0.7% to -0.3%) in patients followed by CHCT. CONCLUSIONS Despite CHCT following older patients with higher comorbidity burden, there appeared to be a protective effect. Patients followed by CHCT were more likely to present to acute care and less likely to die inpatient.
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Affiliation(s)
- Laura C Myers
- Division of Research, Kaiser Permanente, Oakland, California, USA
- The Permanente Medical Group Inc, Oakland, California, USA
| | - Brian L Lawson
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Gabriel J Escobar
- Division of Research, Kaiser Permanente, Oakland, California, USA
- The Permanente Medical Group Inc, Oakland, California, USA
| | - Kathleen A Daly
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | | | - Richard Dlott
- The Permanente Medical Group Inc, Oakland, California, USA
| | - Catherine Lee
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Vincent Liu
- Division of Research, Kaiser Permanente, Oakland, California, USA
- The Permanente Medical Group Inc, Oakland, California, USA
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Kohn R, Harhay MO, Weissman GE, Urbanowicz R, Wang W, Anesi GL, Scott S, Bayes B, Greysen SR, Halpern SD, Kerlin MP. A Data-Driven Analysis of Ward Capacity Strain Metrics That Predict Clinical Outcomes Among Survivors of Acute Respiratory Failure. J Med Syst 2023; 47:83. [PMID: 37542590 DOI: 10.1007/s10916-023-01978-5] [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: 05/19/2022] [Accepted: 07/18/2023] [Indexed: 08/07/2023]
Abstract
Supply-demand mismatch of ward resources ("ward capacity strain") alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors. In a retrospective cohort of ARF survivors transferred from intensive care units (ICUs) to wards in five hospitals from 4/2017-12/2019, we applied 11 machine learning (ML) models to identify ward strain measures during the first 24 hours after transfer most predictive of outcomes. Measures spanned patient volume (census, admissions, discharges), staff workload (medications administered, off-ward transports, transfusions, isolation precautions, patients per respiratory therapist and nurse), and average patient acuity (Laboratory Acute Physiology Score version 2, ICU transfers) domains. The cohort included 5,052 visits in 43 wards. Median age was 65 years (IQR 56-73); 2,865 (57%) were male; and 2,865 (57%) were white. 770 (15%) patients died in the hospital or had hospice discharges, and 2,628 (61%) were discharged home and 964 (23%) to skilled nursing facilities (SNFs). Ward admissions, isolation precautions, and hospital admissions most consistently predicted in-hospital mortality across ML models. Patients per nurse most consistently predicted discharge to home and SNF, and medications administered predicted SNF discharge. In this hypothesis-generating analysis of candidate ward strain variables' prediction of outcomes among ARF survivors, several variables emerged as consistently predictive of key outcomes across ML models. These findings suggest targets for future inferential studies to elucidate mechanisms of ward strain's adverse effects.
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Affiliation(s)
- Rachel Kohn
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Michael O Harhay
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gary E Weissman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Wei Wang
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - George L Anesi
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefania Scott
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - S Ryan Greysen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Halpern
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meeta Prasad Kerlin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Anesi GL, Xiong RA, Delgado MK. Frequency and Trends of Pre-Pandemic Surge Periods in U.S. Emergency Departments, 2006-2019. Crit Care Explor 2023; 5:e0954. [PMID: 37614798 PMCID: PMC10443743 DOI: 10.1097/cce.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES To quantify the frequency, outside of the pandemic setting, with which individual healthcare facilities faced surge periods due to severe increases in demand for emergency department (ED) care. DESIGN Retrospective cohort study. SETTING U.S. EDs. PATIENTS All ED encounters in the all-payer, nationally representative Nationwide Emergency Department Sample from the Healthcare Cost and Utilization Project, 2006-2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Frequency of surge periods defined as ED months in which an individual facility ED saw a greater than 50% increase in ED visits per month above facility-/calendar month-specific medians. During 2006-2019, 3,317 U.S. EDs reported 354,534,229 ED visits across 142,035 ED months. Fifty-seven thousand four hundred ninety-five ED months (40.5%) during the study period had a 0% to 50% increase in ED visits that month above facility-specific medians and 1,952 ED months (1.4%) qualified as surge periods and had a greater than 50% increase in ED visits that month above facility-specific medians. These surge months were experienced by 397 unique facility EDs (12.0%). Compared with 2006, the most proximal pre-pandemic period of 2016-2019 had a notably elevated likelihood of ED-month surge periods (odds ratios [ORs], 2.36-2.84; all p < 0.0005). Compared with the calendar month of January, the winter ED months in December through March have similar likelihood of an ED-month qualifying as a surge period (ORs, 0.84-1.03; all p > 0.05), while the nonwinter ED months in April through November have a lower likelihood of an ED-month qualifying as a surge period (ORs, 0.65-0.81; all p < 0.05). CONCLUSIONS Understanding the frequency of surges in demand for ED care-which appear to have increased in frequency even before the COVID-19 pandemic and are concentrated in winter months-is necessary to better understand the burden of potential and realized acute surge events and to inform cost-effectiveness preparedness strategies.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ruiying Aria Xiong
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - M Kit Delgado
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Anesi GL, Savarimuthu SM, Invernizzi J, Hyman R, Ramkillawan A, Eddey C, Wise RD, Smith MTD. ICU Mortality Across Prepandemic and Pandemic Cohorts in a Resource-Limited Setting: A Critical Care Resiliency Analysis From South Africa. CHEST CRITICAL CARE 2023; 1:100005. [PMID: 39211576 PMCID: PMC11360720 DOI: 10.1016/j.chstcc.2023.100005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Hospital adaptation and resiliency, required during public health emergencies to optimize outcomes, are understudied especially in resource-limited settings. RESEARCH QUESTION What are the prepandemic and pandemic critical illness outcomes in a resource-limited setting and in the context of capacity strain? STUDY DESIGN AND METHODS We performed a retrospective cohort study among patients admitted to ICUs at two public hospitals in the KwaZulu-Natal Department of Health in South Africa preceding and during the COVID-19 pandemic (2017-2022). We used multivariate logistic regression to analyze the association between three patient cohorts (prepandemic non-COVID-19, pandemic non-COVID-19, and pandemic COVID-19) and ICU capacity strain and the primary outcome of ICU mortality. RESULTS Three thousand two hundred twenty-one patients were admitted to the ICU during the prepandemic period and 2,539 patients were admitted to the ICU during the pandemic period (n = 375 [14.8%] with COVID-19 and n = 2,164 [85.2%] without COVID-19). The prepandemic and pandemic non-COVID-19 cohorts were similar. Compared with the non-COVID-19 cohorts, the pandemic COVID-19 cohort showed older age, higher rates of chronic cardiovascular disease and diabetes, less extrapulmonary organ dysfunction, and longer ICU length of stay. Compared with the prepandemic non-COVID-19 cohort, the pandemic non-COVID-19 cohort showed similar odds of ICU mortality (OR, 1.06; 95% CI, 0.90-1.25; P = .50) whereas the pandemic COVID-19 cohort showed significantly increased odds of ICU mortality (OR, 3.91; 95% CI, 3.03-5.05 P < .0005). ICU occupancy was not associated with ICU mortality in either the COVID-19 cohort (OR, 1.05 per 10% change in ICU occupancy; 95% CI, 0.96-1.14; P = .27) or the pooled non-COVID-19 cohort (OR, 1.01 per 10% change in ICU occupancy; 95% CI, 0.98-1.03; P = .52). INTERPRETATION Patients admitted to the ICU before and during the pandemic without COVID-19 were broadly similar in clinical characteristics and outcomes, suggesting critical care resiliency, whereas patients admitted to the ICU with COVID-19 showed important clinical differences and significantly higher mortality.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stella M Savarimuthu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Jonathan Invernizzi
- Department of Anaesthesia and Critical Care, Harry Gwala Regional Hospital, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Robyn Hyman
- Department of Anaesthesia and Critical Care, Harry Gwala Regional Hospital, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Arisha Ramkillawan
- Department of Anaesthesia and Critical Care, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Creaghan Eddey
- Department of Anaesthesia and Critical Care, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Robert D Wise
- Department of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Intensive Care Department, John Radcliffe Hospital, Oxford University Trust Hospitals, Oxford, England
| | - Michelle T D Smith
- Department of Anaesthesia and Critical Care, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
- Department of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Dukewich M, Liu CH, Weinberg EM, Mahmud N, Reddy KR. Clinical Predictors of Intensive Care Unit Transfer in Admitted Patients with Cirrhosis. Dig Dis Sci 2023; 68:2344-2359. [PMID: 36781572 PMCID: PMC10192086 DOI: 10.1007/s10620-023-07856-x] [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: 06/10/2022] [Accepted: 01/28/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Patients with cirrhosis are at high risk of mortality after organ failure that requires ICU care. There have been attempts to predict which patients are at highest risk, with some success found in adapting liver disease-specific scoring systems with clinical variables commonly associated with critical illness. However, the clinical factors predictive of which patients with cirrhosis are most at-risk of needing ICU level care are unknown. AIMS Our study set out to better understand which clinical variables were associated with need for ICU care in patients with cirrhosis. METHODS Retrospective analysis of admitted patients with cirrhosis at single tertiary care center. RESULTS Patients with cirrhosis admitted to our center were categorized into three groups: those without ICU transfer, those admitted to the ICU directly from the emergency department (ED), and those admitted to the ICU from the medicine floor. These groups differed in mortality at 30 days (3.5% vs. 15% vs. 25%, P < 0.001) and at subsequent intervals up to 1 year. These groups differed in indication for ICU transfer, with GI bleed, hemorrhagic shock, hepatic encephalopathy, and hyponatremia occurring more in the ED-to-ICU group, while respiratory failure was more common in the floor-to-ICU group. In multivariable analysis, factors associated with ICU transfer included worsened kidney function, anemia, hyponatremia, leukocytosis, and the decision to obtain a lactate level. Similar analysis with only floor-to-ICU patients found that ICU transfer was associated with hypoalbuminemia, hyponatremia, hypotension, and SIRS score. CONCLUSION Our study found significant differences in mortality among three distinct groups of patients with cirrhosis. A risk factor model for ICU transfer found that variables both specific and nonspecific to liver disease were associated with ICU transfer, with between-group differences supporting the idea of different clinical phenotypes and suggesting factors that should be considered in early triage and assessment of hospitalized patients with cirrhosis.
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Affiliation(s)
- Matthew Dukewich
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Chung-Heng Liu
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, South Pavilion 4th Floor, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Batten JN, Caruso P, Metaxa V. More than patient benefit: taking a broader view of ICU admission decisions. Intensive Care Med 2023; 49:556-558. [PMID: 37145141 DOI: 10.1007/s00134-023-07074-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Jason N Batten
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, USA.
| | - Pedro Caruso
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
- Pulmonary Division of Heart Institute (InCor), São Paulo, Brazil
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
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Chesley CF, Chowdhury M, Small DS, Schaubel D, Liu VX, Lane-Fall MB, Halpern SD, Anesi GL. Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure. JAMA Netw Open 2023; 6:e239739. [PMID: 37155170 PMCID: PMC10167564 DOI: 10.1001/jamanetworkopen.2023.9739] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/07/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Although racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood. Objective To measure disparities in hospital length of stay (LOS) among patients at high risk of adverse outcomes who present with sepsis and/or ARF and do not immediately require life support and to quantify associations with patient- and hospital-level factors. Design, Setting, and Participants This matched retrospective cohort study used electronic health record data from 27 acute care teaching and community hospitals across the Philadelphia metropolitan and northern California areas between January 1, 2013, and December 31, 2018. Matching analyses were performed between June 1 and July 31, 2022. The study included 102 362 adult patients who met clinical criteria for sepsis (n = 84 685) or ARF (n = 42 008) with a high risk of death at the time of presentation to the emergency department but without an immediate requirement for invasive life support. Exposures Racial or ethnic minority self-identification. Main Outcomes and Measures Hospital LOS, defined as the time from hospital admission to the time of discharge or inpatient death. Matches were stratified by racial and ethnic minority patient identity, comparing Asian and Pacific Islander patients, Black patients, Hispanic patients, and multiracial patients with White patients in stratified analyses. Results Among 102 362 patients, the median (IQR) age was 76 (65-85) years; 51.5% were male. A total of 10.2% of patients self-identified as Asian American or Pacific Islander, 13.7% as Black, 9.7% as Hispanic, 60.7% as White, and 5.7% as multiracial. After matching racial and ethnic minority patients to White patients on clinical presentation characteristics, hospital capacity strain, initial intensive care unit admission, and the occurrence of inpatient death, Black patients experienced longer LOS relative to White patients in fully adjusted matches (sepsis: 1.26 [95% CI, 0.68-1.84] days; ARF: 0.97 [95% CI, 0.05-1.89] days). Length of stay was shorter among Asian American and Pacific Islander patients with ARF (-0.61 [95% CI, -0.88 to -0.34] days) and Hispanic patients with sepsis (-0.22 [95% CI, -0.39 to -0.05] days) or ARF (-0.47 [-0.73 to -0.20] days). Conclusions and Relevance In this cohort study, Black patients with severe illness who presented with sepsis and/or ARF experienced longer LOS than White patients. Hispanic patients with sepsis and Asian American and Pacific Islander and Hispanic patients with ARF both experienced shorter LOS. Because matched differences were independent of commonly implicated clinical presentation-related factors associated with disparities, identification of additional mechanisms that underlie these disparities is warranted.
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Affiliation(s)
- Christopher F. Chesley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Dylan S. Small
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Wharton Department of Statistics and Data Science, University of Pennsylvania, Philadelphia
| | - Douglas Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Meghan B. Lane-Fall
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Anesi GL, Dress E, Chowdhury M, Wang W, Small DS, Delgado MK, Bayes B, Szymczak JE, Glassman LW, Barreda FX, Weiner JZ, Escobar GJ, Halpern SD, Liu VX. Among-Hospital Variation in Intensive Care Unit Admission Practices and Associated Outcomes for Patients with Acute Respiratory Failure. Ann Am Thorac Soc 2023; 20:406-413. [PMID: 35895629 PMCID: PMC9993147 DOI: 10.1513/annalsats.202205-429oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: We have previously shown that hospital strain is associated with intensive care unit (ICU) admission and that ICU admission, compared with ward admission, may benefit certain patients with acute respiratory failure (ARF). Objectives: To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. Methods: We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. Results: There was significant among-hospital variation in ICU admission rates, in hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF (n = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared with the ward, but among the 27 hospitals (n = 224-3,324), this effect varied from 5.85 days shorter (95% confidence interval [CI], -8.84 to -2.86; P < 0.001) to 4.38 days longer (95% CI, 1.86-6.90; P = 0.001). Corresponding ranges for in-hospital mortality with ICU compared with ward admission revealed odds ratios from 0.08 (95% CI, 0.01-0.56; P < 0.007) to 8.89 (95% CI, 1.60-79.85; P = 0.016) among patients with ARF (pooled odds ratio, 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. Conclusions: Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine
- Leonard Davis Institute of Health Economics
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Erich Dress
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | | | - M. Kit Delgado
- Leonard Davis Institute of Health Economics
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, and
| | - Brian Bayes
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Lindsay W. Glassman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | | | | | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine
- Leonard Davis Institute of Health Economics
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
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11
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Admon AJ, Ansari S. The Ward or the Intensive Care Unit: Is It All Relative? Ann Am Thorac Soc 2023; 20:364-366. [PMID: 36856718 PMCID: PMC9993155 DOI: 10.1513/annalsats.202211-945ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Affiliation(s)
- Andrew J Admon
- Department of Internal Medicine and
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, LTC Charles Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; and
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Sardar Ansari
- Department of Emergency Medicine, Medical School, and
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
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12
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Anesi GL, Dress E, Chowdhury M, Wang W, Small DS, Delgado MK, Bayes B, Barreda FX, Halpern SD, Liu VX. Hospital Strain and Variation in Sepsis ICU Admission Practices and Associated Outcomes. Crit Care Explor 2023; 5:e0858. [PMID: 36751517 PMCID: PMC9897373 DOI: 10.1097/cce.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To understand how strain-process-outcome relationships in patients with sepsis may vary among hospitals. DESIGN Retrospective cohort study using a validated hospital capacity strain index as a within-hospital instrumental variable governing ICU versus ward admission, stratified by hospital. SETTING Twenty-seven U.S. hospitals from 2013 to 2018. PATIENTS High-acuity emergency department patients with sepsis who do not require life support therapies. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The mean predicted probability of ICU admission across strain deciles ranged from 4.9% (lowest ICU-utilizing hospital for sepsis without life support) to 61.2% (highest ICU-utilizing hospital for sepsis without life support). The difference in the predicted probabilities of ICU admission between the lowest and highest strain deciles ranged from 9.0% (least strain-sensitive hospital) to 45.2% (most strain-sensitive hospital). In pooled analyses, emergency department patients with sepsis (n = 90,150) experienced a 1.3-day longer median hospital length of stay (LOS) if admitted initially to the ICU compared with the ward, but across the 27 study hospitals (n = 517-6,564), this effect varied from 9.0 days shorter (95% CI, -10.8 to -7.2; p < 0.001) to 19.0 days longer (95% CI, 16.7-21.3; p < 0.001). Corresponding ranges for inhospital mortality with ICU compared with ward admission revealed odds ratios (ORs) from 0.16 (95% CI, 0.03-0.99; p = 0.04) to 4.62 (95% CI, 1.16-18.22; p = 0.02) among patients with sepsis (pooled OR = 1.48). CONCLUSIONS There is significant among-hospital variation in ICU admission rates for patients with sepsis not requiring life support therapies, how sensitive those ICU admission decisions are to hospital capacity strain, and the association of ICU admission with hospital LOS and hospital mortality. Hospital-level heterogeneity should be considered alongside patient-level heterogeneity in critical and acute care study design and interpretation.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Erich Dress
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Wei Wang
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Dylan S Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - M Kit Delgado
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, CA
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13
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Chesley CF, Anesi GL, Chowdhury M, Schaubel D, Liu VX, Lane-Fall MB, Halpern SD. Characterizing Equity of Intensive Care Unit Admissions for Sepsis and Acute Respiratory Failure. Ann Am Thorac Soc 2022; 19:2044-2052. [PMID: 35830576 PMCID: PMC9743468 DOI: 10.1513/annalsats.202202-115oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022] Open
Abstract
Rationale: Patients who identify as from racial or ethnic minority groups who have sepsis or acute respiratory failure (ARF) experience worse outcomes relative to nonminority patients, but processes of care accounting for disparities are not well-characterized. Objectives: Determine whether reductions in intensive care unit (ICU) admission during hospital-wide capacity strain occur preferentially among patients who identify with racial or ethnic minority groups. Methods: This retrospective cohort among 27 hospitals across the Philadelphia metropolitan area and Northern California between 2013 and 2018 included adult patients with sepsis and/or ARF who did not require life support at the time of hospital admission. An updated model of hospital-wide capacity strain was developed that permitted determination of relationships between patient race, ethnicity, ICU admission, and strain. Results: After adjustment for demographics, disease severity, and study hospital, patients who identified as Asian or Pacific Islander had the highest adjusted ICU admission odds relative to patients who identified as White in both the sepsis and ARF populations (odds ratio, 1.09; P = 0.006 and 1.26; P < 0.001). ICU admission was also elevated for patients with ARF who identified as Hispanic (odds ratio, 1.11; P = 0.020). Capacity strain did not modify differences in ICU admission for patients who identified with a minority group in either disease population (all interactions, P > 0.05). Conclusions: Systematic differences in ICU admission patterns were observed for patients that identified as Asian, Pacific Islander, and Hispanic. However, ICU admission was not restricted from these groups, and capacity strain did not preferentially reduce ICU admission from patients identifying with minority groups. Further characterization of provider decision-making can help contextualize these findings as the result of disparate decision-making or a mechanism of equitable care.
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Affiliation(s)
- Christopher F. Chesley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
| | - Doug Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Meghan B. Lane-Fall
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
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14
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Jain S, Valley TS. Who Receives ICU Care during Times of Strain? Triage and the Potential for Racial Disparities. Ann Am Thorac Soc 2022; 19:1973-1974. [PMID: 36454169 PMCID: PMC9743470 DOI: 10.1513/annalsats.202209-766ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut; and
| | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
- Institute for Healthcare Policy and Innovation, and
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
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15
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Leither LM, Buckel W, Brown SM. Care of the Seriously Ill Patient with SARS-CoV-2. Med Clin North Am 2022; 106:949-960. [PMID: 36280338 PMCID: PMC9364720 DOI: 10.1016/j.mcna.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In late 2019, SARS-CoV-2 caused the greatest global health crisis in a century, impacting all aspects of society. As the COVID-19 pandemic evolved throughout 2020 and 2021, multiple variants emerged, contributing to multiple surges in cases of COVID-19 worldwide. In 2021, highly effective vaccines became available, although the pandemic continues into 2022. There has been tremendous expansion of basic, translational, and clinical knowledge about SARS-CoV-2 and COVID-19 since the pandemic's onset. Treatment options have been rapidly explored, attempting to repurpose preexisting medications in tandem with development and evaluation of novel agents. Care of the seriously ill patient is examined.
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Affiliation(s)
- Lindsay M Leither
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, 5121 South Cottonwood Street, Salt Lake City, UT 84107, USA; Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Whitney Buckel
- Pharmacy Services, Intermountain Healthcare, 4393 S Riverboat Road, Taylorsville, UT 84123, USA
| | - Samuel M Brown
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, 5121 South Cottonwood Street, Salt Lake City, UT 84107, USA; Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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16
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Postelnicu R, Srivastava A, Bhatraju PK, Wurfelc MM, Anesi GL, Gonzalez M, Andrews A, Lutrick K, Kumar VK, Uyeki TM, Cobb PJ, Segal LN, Brett-Major D, Liebler JM, Kratochvil CJ, Mukherjee V, Broadhurst MJ, Lee R, Wyles D, Sevransky JE, Evans L, Landsittel D. Severe Acute Respiratory Infection-Preparedness: Protocol for a Multicenter Prospective Cohort Study of Viral Respiratory Infections. Crit Care Explor 2022; 4:e0773. [PMID: 36284548 PMCID: PMC9586923 DOI: 10.1097/cce.0000000000000773] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Respiratory virus infections cause significant morbidity and mortality ranging from mild uncomplicated acute respiratory illness to severe complications, such as acute respiratory distress syndrome, multiple organ failure, and death during epidemics and pandemics. We present a protocol to systematically study patients with severe acute respiratory infection (SARI), including severe acute respiratory syndrome coronavirus 2, due to respiratory viral pathogens to evaluate the natural history, prognostic biomarkers, and characteristics, including hospital stress, associated with clinical outcomes and severity. DESIGN Prospective cohort study. SETTING Multicenter cohort of patients admitted to an acute care ward or ICU from at least 15 hospitals representing diverse geographic regions across the United States. PATIENTS Patients with SARI caused by infection with respiratory viruses that can cause outbreaks, epidemics, and pandemics. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Measurements include patient demographics, signs, symptoms, and medications; microbiology, imaging, and associated tests; mechanical ventilation, hospital procedures, and other interventions; and clinical outcomes and hospital stress, with specimens collected on days 0, 3, and 7-14 after enrollment and at discharge. The primary outcome measure is the number of consecutive days alive and free of mechanical ventilation (VFD) in the first 30 days after hospital admission. Important secondary outcomes include organ failure-free days before acute kidney injury, shock, hepatic failure, disseminated intravascular coagulation, 28-day mortality, adaptive immunity, as well as immunologic and microbiologic outcomes. CONCLUSIONS SARI-Preparedness is a multicenter study under the collaboration of the Society of Critical Care Medicine Discovery, Resilience Intelligence Network, and National Emerging Special Pathogen Training and Education Center, which seeks to improve understanding of prognostic factors associated with worse outcomes and increased resource utilization. This can lead to interventions to mitigate the clinical impact of respiratory virus infections associated with SARI.
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Affiliation(s)
- Radu Postelnicu
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Avantika Srivastava
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, Seattle, WA
| | - Mark M. Wurfelc
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, Seattle, WA
| | - George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Adair Andrews
- Society of Critical Care Medicine, Mount Prospect, IL
| | - Karen Lutrick
- Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | | | - Timothy M. Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Perren J. Cobb
- Departments of Surgery and Anesthesiology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
| | - Leopoldo N. Segal
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - David Brett-Major
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE., Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE
| | - Janice M. Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - M. Jana Broadhurst
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE., Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Richard Lee
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, CA
| | - David Wyles
- Division of Infectious Diseases, Denver Health Medical Center, Denver, CO
| | - Jonathan E. Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep, School of Medicine, Emory University, Atlanta, GA., Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, Seattle, WA
| | - Douglas Landsittel
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN
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17
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Ginestra JC, Kohn R, Hubbard RA, Crane-Droesch A, Halpern SD, Kerlin MP, Weissman GE. Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis. Ann Am Thorac Soc 2022; 19:1525-1533. [PMID: 35312462 PMCID: PMC9447380 DOI: 10.1513/annalsats.202112-1360oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/18/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared with those with community-acquired sepsis. Capacity strain, the extent to which demand for hospital resources exceeds availability, thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. Objectives: Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. Methods: This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from community-acquired sepsis by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. Results: A total of 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (interquartile range, 0.4-22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% confidence interval [CI], 2.4-4.8 h) to 6.8 hours (95% CI, 5.3-8.4 h) at census levels 2 standard deviations (SDs) below and above the ward-specific mean, respectively. Each 1-SD increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI, 0.32-1.29 h). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. Conclusions: Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.
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Affiliation(s)
- Jennifer C. Ginestra
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rachel Kohn
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rebecca A. Hubbard
- Palliative and Advanced Illness Research (PAIR) Center
- Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Crane-Droesch
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
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18
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Prower E, Hadfield S, Saha R, Woo T, Ang KM, Metaxa V. A critical care outreach team under strain - Evaluation of the service provided to patients with haematological malignancy during the Covid-19 pandemic. J Crit Care 2022; 71:154109. [PMID: 35843047 PMCID: PMC9282870 DOI: 10.1016/j.jcrc.2022.154109] [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: 04/03/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/25/2022]
Abstract
Purpose Critical Care Outreach Teams (CCOTs) have been associated with improved outcomes in patients with haematological malignancy (HM). This study aims to describe CCOT activation by patients with HM before and during the Covid-19 pandemic, assess amny association with worse outcomes, and examine the psychological impact on the CCOT. Materials and methods A retrospective, mixed-methods analysis was performed in HM patients reviewed by the CCOT over a two-year period, 01 July 2019 to 31 May 2021. Results The CCOT increased in size during the surge period and reviewed 238 HM patients, less than in the pre- and post-surge periods. ICU admission in the baseline, surge and the non-surge periods were 41.7%, 10.4% and 47.9% respectively. ICU mortality was 22.5%, 0% and 21.7% for the same times. Time to review was significantly decreased (p = 0.012). Semi-structured interviews revealed four themes of psychological distress: 1) time-critical work; 2) non-evidence based therapies; 3) feelings of guilt; 4) increased decision-making responsibility. Conclusions Despite the increase in total hospital referrals, the number of patients with HM that were reviewed during the surge periods decreased, as did their ICU admission rate and mortality. The quality of care provided was not impaired, as reflected by the number of patients receiving bedside reviews and the shorter-than-pre-pandemic response time.
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Affiliation(s)
- Emma Prower
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Sophie Hadfield
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Rohit Saha
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Woo
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Kar Mun Ang
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK.
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19
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Getting What You Pay For. Ann Am Thorac Soc 2022; 19:901-904. [PMID: 35648083 PMCID: PMC9169134 DOI: 10.1513/annalsats.202201-037ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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20
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Lee C, Lawson BL, Mann AJ, Liu VX, Myers LC, Schuler A, Escobar GJ. Exploratory analysis of novel electronic health record variables for quantification of healthcare delivery strain, prediction of mortality, and prediction of imminent discharge. J Am Med Inform Assoc 2022; 29:1078-1090. [PMID: 35290460 PMCID: PMC9093028 DOI: 10.1093/jamia/ocac037] [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: 12/07/2021] [Revised: 02/15/2022] [Accepted: 03/02/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To explore the relationship between novel, time-varying predictors for healthcare delivery strain (eg, counts of patient orders per hour) and imminent discharge and in-hospital mortality. MATERIALS AND METHODS We conducted a retrospective cohort study using data from adults hospitalized at 21 Kaiser Permanente Northern California hospitals between November 1, 2015 and October 31, 2020 and the nurses caring for them. Patient data extracted included demographics, diagnoses, severity measures, occupancy metrics, and process of care metrics (eg, counts of intravenous drip orders per hour). We linked these data to individual registered nurse records and created multiple dynamic, time-varying predictors (eg, mean acute severity of illness for all patients cared for by a nurse during a given hour). All analyses were stratified by patients' initial hospital unit (ward, stepdown unit, or intensive care unit). We used discrete-time hazard regression to assess the association between each novel time-varying predictor and the outcomes of discharge and mortality, separately. RESULTS Our dataset consisted of 84 162 161 hourly records from 954 477 hospitalizations. Many novel time-varying predictors had strong associations with the 2 study outcomes. However, most of the predictors did not merely track patients' severity of illness; instead, many of them only had weak correlations with severity, often with complex relationships over time. DISCUSSION Increasing availability of process of care data from automated electronic health records will permit better quantification of healthcare delivery strain. This could result in enhanced prediction of adverse outcomes and service delays. CONCLUSION New conceptual models will be needed to use these new data elements.
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Affiliation(s)
- Catherine Lee
- Division of Research, Kaiser Permanente, Oakland, California 94612, USA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California 91101, USA
| | - Brian L Lawson
- Division of Research, Kaiser Permanente, Oakland, California 94612, USA
| | - Ariana J Mann
- Electrical Engineering, Stanford University, Stanford, California 94305, USA
| | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, California 94612, USA.,Intensive Care Unit, Kaiser Permanente Medical Center, Santa Clara, California 95051, USA
| | - Laura C Myers
- Division of Research, Kaiser Permanente, Oakland, California 94612, USA.,Intensive Care Unit, Kaiser Permanente Medical Center, Walnut Creek, California 94596, USA
| | - Alejandro Schuler
- Center for Targeted Learning, School of Public Health, University of California, Berkeley, California 94704, USA
| | - Gabriel J Escobar
- Division of Research, Kaiser Permanente, Oakland, California 94612, USA
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21
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Anesi GL, Liu VX, Chowdhury M, Small DS, Wang W, Delgado MK, Bayes B, Dress E, Escobar GJ, Halpern SD. Association of ICU Admission and Outcomes in Sepsis and Acute Respiratory Failure. Am J Respir Crit Care Med 2022; 205:520-528. [PMID: 34818130 PMCID: PMC8906481 DOI: 10.1164/rccm.202106-1350oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness. Objectives: To measure the benefits of ICU admission for patients with sepsis or acute respiratory failure. Methods: At 27 United States hospitals across two health systems from 2013 to 2018, we performed a retrospective cohort study using two-stage instrumental variable quantile regression with a strong instrument (hospital capacity strain) governing ICU versus ward admission among high-acuity patients (i.e., laboratory-based acute physiology score v2 ⩾ 100) with sepsis and/or acute respiratory failure who did not require mechanical ventilation or vasopressors in the emergency department. Measurements and Main Results: Among patients with sepsis (n = 90,150), admission to the ICU was associated with a 1.32-day longer hospital length of stay (95% confidence interval [CI], 1.01-1.63; P < 0.001) (when treating deaths as equivalent to long lengths of stay) and higher in-hospital mortality (odds ratio, 1.48; 95% CI, 1.13-1.88; P = 0.004). Among patients with respiratory failure (n = 45,339), admission to the ICU was associated with a 0.82-day shorter hospital length of stay (95% CI, -1.17 to -0.46; P < 0.001) and reduced in-hospital mortality (odds ratio, 0.75; 95% CI, 0.57-0.96; P = 0.04). In sensitivity analyses of length of stay, excluding, ignoring, or censoring death, results were similar in sepsis but not in respiratory failure. In subgroup analyses, harms of ICU admission for patients with sepsis were concentrated among older patients and those with fewer comorbidities, and the benefits of ICU admission for patients with respiratory failure were concentrated among older patients, highest-acuity patients, and those with more comorbidities. Conclusions: Among high-acuity patients with sepsis who did not require life support in the emergency department, initial admission to the ward, compared with the ICU, was associated with shorter length of stay and improved survival, whereas among patients with acute respiratory failure, triage to the ICU compared with the ward was associated with improved survival.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care,,Palliative and Advanced Illness Research (PAIR) Center, and,Leonard Davis Institute of Health Economics
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | | | - Dylan S. Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Wei Wang
- Palliative and Advanced Illness Research (PAIR) Center, and
| | - M. Kit Delgado
- Palliative and Advanced Illness Research (PAIR) Center, and,Center for Emergency Care Policy and Research, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania;,Leonard Davis Institute of Health Economics
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, and
| | - Erich Dress
- Palliative and Advanced Illness Research (PAIR) Center, and
| | | | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care,,Palliative and Advanced Illness Research (PAIR) Center, and,Leonard Davis Institute of Health Economics
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22
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Barbash IJ, Gershengorn HB. Hospital Capacity Strain as a Window into the Value of ICU Admission: Some Answers, More Questions. Am J Respir Crit Care Med 2021; 205:485-487. [PMID: 34890536 PMCID: PMC8906479 DOI: 10.1164/rccm.202111-2570ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ian J Barbash
- University of Pittsburgh School of Medicine, 12317, Pulmonary and Critical Care Medicine, Pittsburgh, Pennsylvania, United States;
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23
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Anesi GL, Kerlin MP. The impact of resource limitations on care delivery and outcomes: routine variation, the coronavirus disease 2019 pandemic, and persistent shortage. Curr Opin Crit Care 2021; 27:513-519. [PMID: 34267075 PMCID: PMC8416747 DOI: 10.1097/mcc.0000000000000859] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Resource limitation, or capacity strain, has been associated with changes in care delivery, and in some cases, poorer outcomes among critically ill patients. This may result from normal variation in strain on available resources, chronic strain in persistently under-resourced settings, and less commonly because of acute surges in demand, as seen during the coronavirus disease 2019 (COVID-19) pandemic. RECENT FINDINGS Recent studies confirmed existing evidence that high ICU strain is associated with ICU triage decisions, and that ICU strain may be associated with ICU patient mortality. Studies also demonstrated earlier discharge of ICU patients during high strain, suggesting that strain may promote patient flow efficiency. Several studies of strain resulting from the COVID-19 pandemic provided support for the concept of adaptability - that the surge not only caused detrimental strain but also provided experience with a novel disease entity such that outcomes improved over time. Chronically resource-limited settings faced even more challenging circumstances because of acute-on-chronic strain during the pandemic. SUMMARY The interaction between resource limitation and care delivery and outcomes is complex and incompletely understood. The COVID-19 pandemic provides a learning opportunity for strain response during both pandemic and nonpandemic times.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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24
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Pilcher DV, Duke G, Rosenow M, Coatsworth N, O’Neill G, Tobias TA, McGloughlin S, Holley A, Warrillow S, Cattigan C, Huckson S, Sberna G, McClure J. Assessment of a novel marker of ICU strain, the ICU Activity Index, during the COVID-19 pandemic in Victoria, Australia. CRIT CARE RESUSC 2021; 23:300-307. [PMID: 38046069 PMCID: PMC10692615 DOI: 10.51893/2021.3.oa7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To validate a real-time Intensive Care Unit (ICU) Activity Index as a marker of ICU strain from daily data available from the Critical Health Resource Information System (CHRIS), and to investigate the association between this Index and the need to transfer critically ill patients during the coronavirus disease 2019 (COVID-19) pandemic in Victoria, Australia. Design: Retrospective observational cohort study. Setting: All 45 hospitals with an ICU in Victoria, Australia. Participants: Patients in all Victorian ICUs and all critically ill patients transferred between Victorian hospitals from 27 June to 6 September 2020. Main outcome measure: Acute interhospital transfer of one or more critically ill patients per day from one site to an ICU in another hospital. Results: 150 patients were transported over 61 days from 29 hospitals (64%). ICU Activity Index scores were higher on days when critical care transfers occurred (median, 1.0 [IQR, 0.4-1.7] v 0.6 [IQR, 0.3-1.2]; P < 0.001). Transfers were more common on days of higher ICU occupancy, higher numbers of ventilated or COVID-19 patients, and when more critical care staff were unavailable. The highest ICU Activity Index scores were observed at hospitals in north-western Melbourne, where the COVID-19 disease burden was greatest. After adjusting for confounding factors, including occupancy and lack of available ICU staff, a rising ICU Activity Index score was associated with an increased risk of a critical care transfer (odds ratio, 4.10; 95% CI, 2.34-7.18; P < 0.001). Conclusions: The ICU Activity Index appeared to be a valid marker of ICU strain during the COVID-19 pandemic. It may be useful as a real-time clinical indicator of ICU activity and predict the need for redistribution of critical ill patients.
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Affiliation(s)
- David V. Pilcher
- Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
- Department of Intensive Care, Alfred Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Graeme Duke
- Intensive Care Service, Eastern Health, Melbourne, VIC, Australia
| | - Melissa Rosenow
- Adult Retrieval Victoria, Ambulance Victoria, Melbourne, VIC, Australia
| | - Nicholas Coatsworth
- Australian Government Department of Health, Canberra, ACT, Australia
- Australian National University Medical School, Canberra, ACT, Australia
| | - Genevieve O’Neill
- Australian Government Department of Health, Canberra, ACT, Australia
| | - Tracey A. Tobias
- Adult Retrieval Victoria, Ambulance Victoria, Melbourne, VIC, Australia
| | - Steven McGloughlin
- Department of Intensive Care, Alfred Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Anthony Holley
- Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Steven Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Claire Cattigan
- Department of Intensive Care, University Hospital Geelong, Geelong, VIC, Australia
| | - Sue Huckson
- Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Gian Sberna
- Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Jason McClure
- Department of Intensive Care, Alfred Health, Melbourne, VIC, Australia
- Adult Retrieval Victoria, Ambulance Victoria, Melbourne, VIC, Australia
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25
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Khemani RG, Lee JT, Wu D, Schenck EJ, Hayes MM, Kritek PA, Mutlu GM, Gershengorn HB, Coudroy R. Update in Critical Care 2020. Am J Respir Crit Care Med 2021; 203:1088-1098. [PMID: 33734938 DOI: 10.1164/rccm.202102-0336up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jessica T Lee
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Wu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York.,NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Patricia A Kritek
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of Washington Seattle, Washington
| | - Gökhan M Mutlu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Rémi Coudroy
- Institut National de la Santé et de la Recherche Médicale, Poitiers, France; and.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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26
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Ashana DC, Anesi GL, Liu VX, Escobar GJ, Chesley C, Eneanya ND, Weissman GE, Miller WD, Harhay MO, Halpern SD. Equitably Allocating Resources during Crises: Racial Differences in Mortality Prediction Models. Am J Respir Crit Care Med 2021; 204:178-186. [PMID: 33751910 PMCID: PMC8759151 DOI: 10.1164/rccm.202012-4383oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objectives: To test the prognostic accuracy of the SOFA score and version 2 of the Laboratory-based Acute Physiology Score (LAPS2) among Black and white patients. Methods: We included Black and white patients admitted for sepsis or acute respiratory failure at 27 hospitals. We calculated the discrimination and calibration for in-hospital mortality of SOFA, LAPS2, and modified versions of each, including categorical SOFA groups recommended in a popular CSC and a SOFA score without creatinine to reduce the influence of race. Measurements and Main Results: Of 113,158 patients, 27,644 (24.4%) identified as Black. The LAPS2 demonstrated higher discrimination (area under the receiver operating characteristic curve [AUC], 0.76; 95% confidence interval [CI], 0.76-0.77) than the SOFA score (AUC, 0.68; 95% CI, 0.68-0.69). The LAPS2 was also better calibrated than the SOFA score, but both underestimated in-hospital mortality for white patients and overestimated in-hospital mortality for Black patients. Thus, in a simulation using observed mortality, 81.6% of Black patients were included in lower-priority CSC categories, and 9.4% of all Black patients were erroneously excluded from receiving the highest prioritization. The SOFA score without creatinine reduced racial miscalibration. Conclusions: Using SOFA in CSCs may lead to racial disparities in resource allocation. More equitable mortality prediction scores are needed.
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Affiliation(s)
- Deepshikha Charan Ashana
- Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine, Duke University, Durham, North
Carolina;,Palliative and Advanced Illness Research
Center
| | - George L. Anesi
- Palliative and Advanced Illness Research
Center,,Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine,,Leonard Davis Institute of Health
Economics
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente,
Oakland, California; and
| | | | - Christopher Chesley
- Palliative and Advanced Illness Research
Center,,Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine,,Leonard Davis Institute of Health
Economics
| | - Nwamaka D. Eneanya
- Palliative and Advanced Illness Research
Center,,Leonard Davis Institute of Health
Economics,,Renal-Electrolyte and Hypertension
Division
| | - Gary E. Weissman
- Palliative and Advanced Illness Research
Center,,Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine,,Leonard Davis Institute of Health
Economics
| | - William Dwight Miller
- Section of Pulmonary and Critical Care
Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Michael O. Harhay
- Palliative and Advanced Illness Research
Center,,Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine,,Leonard Davis Institute of Health
Economics,,Department of Biostatistics, Epidemiology,
and Informatics, and
| | - Scott D. Halpern
- Palliative and Advanced Illness Research
Center,,Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine,,Leonard Davis Institute of Health
Economics,,Department of Biostatistics, Epidemiology,
and Informatics, and,Department of Medical Ethics and Health
Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania
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27
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Usher MG, Tourani R, Simon G, Tignanelli C, Jarabek B, Strauss CE, Waring SC, Klyn NAM, Kealey BT, Tambyraja R, Pandita D, Baum KD. Overcoming gaps: regional collaborative to optimize capacity management and predict length of stay of patients admitted with COVID-19. JAMIA Open 2021; 4:ooab055. [PMID: 34350391 PMCID: PMC8327377 DOI: 10.1093/jamiaopen/ooab055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/12/2021] [Accepted: 07/06/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Ensuring an efficient response to COVID-19 requires a degree of inter-system coordination and capacity management coupled with an accurate assessment of hospital utilization including length of stay (LOS). We aimed to establish optimal practices in inter-system data sharing and LOS modeling to support patient care and regional hospital operations. Materials and Methods We completed a retrospective observational study of patients admitted with COVID-19 followed by 12-week prospective validation, involving 36 hospitals covering the upper Midwest. We developed a method for sharing de-identified patient data across systems for analysis. From this, we compared 3 approaches, generalized linear model (GLM) and random forest (RF), and aggregated system level averages to identify features associated with LOS. We compared model performance by area under the ROC curve (AUROC). Results A total of 2068 patients were included and used for model derivation and 597 patients for validation. LOS overall had a median of 5.0 days and mean of 8.2 days. Consistent predictors of LOS included age, critical illness, oxygen requirement, weight loss, and nursing home admission. In the validation cohort, the RF model (AUROC 0.890) and GLM model (AUROC 0.864) achieved good to excellent prediction of LOS, but only marginally better than system averages in practice. Conclusion Regional sharing of patient data allowed for effective prediction of LOS across systems; however, this only provided marginal improvement over hospital averages at the aggregate level. A federated approach of sharing aggregated system capacity and average LOS will likely allow for effective capacity management at the regional level.
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Affiliation(s)
- Michael G Usher
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Roshan Tourani
- Department of Medicine, Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Gyorgy Simon
- Department of Medicine, Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Christopher Tignanelli
- Department of Medicine, Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Division of Acute Care Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Bryan Jarabek
- Department of Informatics, M Health Fairview, Minneapolis, Minnesota, USA
| | - Craig E Strauss
- Minneapolis Heart Institute Center for Healthcare Delivery Innovation, Minneapolis Heart Institute, Allina Health, Minneapolis, Minnesota, USA
| | - Stephen C Waring
- Essentia Institute of Rural Health, Essential Health, Duluth, Minnesota, USA
| | - Niall A M Klyn
- Information Services, Essentia Health, Duluth, Minnesota, USA
| | - Burke T Kealey
- Internal Medicine, HealthPartners, St. Paul, Minnesota, USA
| | - Rabindra Tambyraja
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Deepti Pandita
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Karyn D Baum
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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28
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Anesi GL, Chelluri J, Qasim ZA, Chowdhury M, Kohn R, Weissman GE, Bayes B, Delgado MK, Abella BS, Halpern SD, Greenwood JC. Association of an Emergency Department-embedded Critical Care Unit with Hospital Outcomes and Intensive Care Unit Use. Ann Am Thorac Soc 2020; 17:1599-1609. [PMID: 32697602 PMCID: PMC7706601 DOI: 10.1513/annalsats.201912-912oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 07/22/2020] [Indexed: 12/15/2022] Open
Abstract
Rationale: A small but growing number of hospitals are experimenting with emergency department-embedded critical care units (CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF).Objectives: To evaluate the potential impact of an emergency department-embedded CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the emergency department to a medical ward or intensive care unit (ICU) from January 2016 to December 2017.Methods: The exposure was eligibility for admission to the emergency department-embedded CCU, which was defined as meeting a clinical definition for sepsis or ARF and admission to the emergency department during the intervention period on a weekday. The primary outcome was hospital length of stay (LOS); secondary outcomes included total emergency department plus ICU LOS, hospital survival, direct admission to the ICU, and unplanned ICU admission. Primary interrupted time series analyses were performed using ordinary least squares regression comparing monthly means. Secondary retrospective cohort and before-after analyses used multivariable Cox proportional hazard and logistic regression.Results: In the baseline and intervention periods, 3,897 patients met the inclusion criteria for sepsis and 1,865 patients met the criteria for ARF. Among patients admitted with sepsis, opening of the emergency department-embedded CCU was not associated with hospital LOS (β = -1.82 d; 95% confidence interval [CI], -4.50 to 0.87; P = 0.17 for the first month after emergency department-embedded CCU opening compared with baseline; β = -0.26 d; 95% CI, -0.58 to 0.06; P = 0.10 for subsequent months). Among patients admitted with ARF, the emergency department-embedded CCU was not associated with a significant change in hospital LOS for the first month after emergency department-embedded CCU opening (β = -3.25 d; 95% CI, -7.86 to 1.36; P = 0.15) but was associated with a 0.64 d/mo shorter hospital LOS for subsequent months (β = -0.64 d; 95% CI, -1.12 to -0.17; P = 0.01). This result persisted among higher acuity patients requiring ventilatory support but was not supported by alternative analytic approaches. Among patients admitted with sepsis who did not require mechanical ventilation or vasopressors in the emergency department, the emergency department-embedded CCU was associated with an initial 9.9% reduction in direct ICU admissions in the first month (β = -0.099; 95% CI, -0.153 to -0.044; P = 0.002), followed by a 1.1% per month increase back toward baseline in subsequent months (β = 0.011; 95% CI, 0.003-0.019; P = 0.009). This relationship was supported by alternative analytic approaches and was not seen in ARF. No associations with emergency department plus ICU LOS, hospital survival, or unplanned ICU admission were observed among patients with sepsis or ARF.Conclusions: The emergency department-embedded CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick patients with sepsis, the emergency department-embedded CCU was initially associated with reduced rates of direct ICU admission from the emergency department. Additional research is necessary to further evaluate the impact and utility of the emergency department-embedded CCU model.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Zaffer A. Qasim
- Department of Emergency Medicine
- Department of Anesthesiology and Critical Care, and
| | | | - Rachel Kohn
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Bayes
- Palliative and Advanced Illness Research Center
| | - M. Kit Delgado
- Palliative and Advanced Illness Research Center
- Department of Emergency Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin S. Abella
- Department of Emergency Medicine
- Center for Resuscitation Science, Perelman School of Medicine, and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John C. Greenwood
- Department of Emergency Medicine
- Center for Resuscitation Science, Perelman School of Medicine, and
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