Characterization of Myocardial Injury in Patients With COVID-19

BACKGROUND

Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data.

OBJECTIVES

This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19.

METHODS

We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization.

RESULTS

A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities.

CONCLUSIONS

Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present.

Quality Outcomes in the Surgical Intensive Care Unit after Electronic Health Record Implementation

BACKGROUND

The electronic health record (EHR) is increasingly viewed as a means to provide more coordinated, patient-centered care. Few studies consider the impact of EHRs on quality of care in the intensive care unit (ICU) setting.

OBJECTIVES

To evaluate key quality measures of a surgical intensive care unit (SICU) following implementation of the Epic EHR system in a tertiary hospital.

METHODS

A retrospective chart review was undertaken to record quality indicators for all patients admitted to the SICU two years before and two years after EHR implementation. Data from the twelve-month period of transition to EHR was excluded. We collected length of stay, mortality, central line associated blood stream infection (CLABSI) rates, Clostridium difficile (C. diff.) colitis rates, readmission rates, and number of coded diagnoses. To control for variation in the patient population over time, the case mix indexes (CMIs) and APACHE II scores were also analyzed.

RESULTS

There was no significant difference in length of stay, C. diff. colitis, readmission rates, or case mix index before and after EHR. After EHR implementation, the rate of central line blood stream infection (CLABSI) per 1 000 catheter days was 85% lower (2.16 vs 0.39; RR, 0.18; 95% CI, 0.05 to 0.61, p < .005), and SICU mortality was 28% lower (12.2 vs 8.8; RR, 1.35; 95% CI, 1.06 to 1.71, p < .01). Moreover, after EHR there was a significant increase in the average number of coded diagnoses from 17.8 to 20.8 (p < .000).

CONCLUSIONS

EHR implementation was statistically associated with reductions in CLABSI rates and SICU mortality. The EHR had an integral role in ongoing quality improvement endeavors which may explain the changes in CLABSI and mortality, and this invites further study of the impact of EHRs on quality of care in the ICU.

Principles and practice of disaster relief: lessons from Haiti

Disaster relief is an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to, and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made. Although it is an important function of local and national governing in the developed countries, it is often wanting in resource-poor, developing countries where, increasingly, catastrophic disasters tend to occur and have the greatest adverse consequences. The devastating January 12, 2010, Haiti earthquake is a case study of the impact of an extreme cataclysm in one of the poorest and most unprepared settings imaginable. As such, it offers useful lessons that are applicable elsewhere in the developing world. Emergency preparedness includes 4 phases: mitigation or prevention, preparedness, response, and recovery. Periods of normalcy are the best times to develop disaster preparedness plans. In resource-poor countries, where dealing with the expenses of daily living is already a burden, such planning is often neglected; and, when disasters strike, it is often with great delay that the assistance from international community can be deployed. In this increasingly interconnected world, the Haiti earthquake and the important international response to it make a strong case for a more proactive intervention of the international community in all phases of emergency management in developing countries, including in mitigation and preparedness, and not just in response and recovery. Predisaster planning can maximize the results of the international assistance and decrease the human and material tolls of inevitable disasters. There should be a minimum standard of preparedness that every country has to maintain and the international assistance to achieve that. International academic medical centers interested in global health could strengthen their programs by prospectively including in them contingency planning for international relief operations. Healthcare professionals of these institutions who travel to disaster zones should rigorously prepare themselves and make provisions for collecting and reporting data, which will enrich the knowledge of this growing activity.