Adjustment For Severity Of Illness Research Articles

Cannabis use disorders and outcome of admission to intensive care: A retrospective multi-centre cohort study

PurposeTo identify factors associated with cannabinoid use among patients admitted to ICU and its impact on survival. MethodsA cohort of adult patients admitted to four public Australian ICUs was assembled. Individuals with mental and behavioural disorders related to cannabinoids were identified using ICD10-AM codes. ResultsOf a cohort of 34,680 admissions among 28,689 adults, 292 (0.8%) had an associated diagnosis related to cannabinoids, of which 66% were classified as harmful use, 26% as dependence syndrome/withdrawal state, 4% as psychosis/delirium, and 4% as acute intoxication. Patients with cannabinoid-use disorders were more likely to be male (73%), tended to be younger (36 vs 62 years), with fewer comorbidities and lesser severity of disease. ICU LOS was longer for those with cannabinoid-use disorders (2 vs 1 days; p < 0.0001). Patients with cannabinoid-use disorders had lower 90-day case-fatality (6% vs. 10%; p = 0.034), however no significant effect on mortality was present after adjustment for severity of illness, age, and chronic comorbidities (p = 1.0). ConclusionCannabinoid-use disorders were present in 0.8% of ICU admissions in our region and were associated with increased ICU length of stay. Further studies are needed to examine cannabinoids as contributors to and modifiers of critical illness.

Days at home alive after major surgery in patients with and without diabetes: an observational cohort study.

We hypothesized that days at home alive up to 30days after surgery (DAH30), a novel patient-centered outcome metric, as well as long-term mortality, would be impaired in patients with type 1 or 2 diabetes mellitus (DM) undergoing major surgery. This cohort study investigated patients > 18years with and without DM presenting for major non-cardiovascular, non-ambulatory surgical procedures at 23 hospitals in Sweden between 2007 and 2014. We identified 290,306 patients. Data were matched with various quality registers. The primary outcome was the composite score, DAH30. The secondary outcome was mortality from 31 to 365days. Using multivariable logistic regression, significant independent risk factors influencing the primary and secondary outcomes were identified, and their adjusted odds ratios were calculated. Patients with DM type 1 and 2 had significantly lower DAH30 as compared to non-diabetics. Patients with DM were older, had higher co-morbid burden, and needed more emergency surgery. After adjustment for illness severity and age, the odds of having a DAH30 less than 15, indicating death and/or complications, were significantly increased for both type 1 and type 2 diabetes. In the year after surgery, DM patients had a higher mortality as compared to those without diabetes. The results of this large cohort study are likely broadly generalizable. To optimize patient and societal outcomes, specific perioperative care pathways for patients with diabetes should be evaluated.

PEDS7: Balloon Atrial Septostomy versus Left Atrial Cannulation for Left Heart Decompression in Children with Dilated Cardiomyopathy and Myocarditis on Extracorporeal Membrane Oxygenation

Purpose: To describe the association of left heart decompression with balloon atrial septostomy (BAS) compared to left atrial (LA) cannulation with survival in children with myocarditis or dilated cardiomyopathy (DCM) on veno-arterial extracorporeal membrane oxygenation (ECMO). Methods: Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ to 18 years old with myocarditis or DCM on ECMO who underwent LA decompression. Only index ECMO run within a hospitalization was included. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes. Results: 321 pediatric ECMO runs were identified. 57% myocarditis (n=183) and 43% DCM (n=138). Survival overall was 74%. 67% underwent balloon atrial septostomy (BAS) and 33% underwent left atrial cannulation. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar between groups. Median ECMO duration was longer in the BAS group compared to LA cannulation (7.2 versus 5.7 days respectively, p=0.002). 82 (78%) were centrally versus peripherally (22%, n=23) cannulated on ECMO in the LA cannulation group, versus 19 (9%) centrally versus 194 (91%) peripherally cannulated in the BAS group. On multivariable analysis, we found LA cannulation (OR 3.68; 95% CI, 1.86-7.31; p<0.001), neurologic complication (OR 5.25; 95% CI, 2.38-11.58; p<0.001), renal complication (OR 2.74; 95% CI, 1.41-5.29; p=0.003), and cardiac complication (OR 2.64; 95% CI, 1.30-5.38; p=0.007) were associated with greater odds of mortality. There were more episodes of pulmonary hemorrhage in the BAS group (n=17) compared to the LA cannulation group (n=2). Conclusions: Our findings indicate better left heart decompression with an LA cannula compared to BAS given a lower incidence of pulmonary hemorrhage in the LA cannulation group. There was a three times greater likelihood for mortality in children with myocarditis and DCM on ECMO who undergo LA cannulation compared to BAS, however, they appear to be fundamentally different cohorts. Further prospective evaluation with adjustment for severity of illness is warranted.

Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department.

To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED). Single-center, retrospective cohort study using ED-visit data between 2015 and 2019. Tertiary academic medical center. Adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival. Dedicated bedside critical care for medical ICU patients by an ED-based intensivist following initial resuscitation by the ED team. Primary outcomes were inhospital mortality and the proportion of patients downgraded to non-ICU status while in the ED within 6 hours of the critical care admission order (ED downgrade <6 hr). A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015-2017) and the intervention period (2017-2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours). Adjustment for severity of illness was performed using the emergency critical care Sequential Organ Failure Assessment (eccSOFA) score. The primary cohort included 2,250 patients. The DiDs for the eccSOFA-adjusted inhospital mortality decreased by 6.0% (95% CI, -11.9 to -0.1) with largest difference in the intermediate illness severity group (DiD, -12.2%; 95% CI, -23.1 to -1.3). The increase in ED downgrade less than 6 hours was not statistically significant (DiD, 4.8%; 95% CI, -0.7 to 10.3%) except in the intermediate group (DiD, 8.8%; 95% CI, 0.2-17.4). The implementation of a novel ECCP was associated with a significant decrease in inhospital mortality among critically ill medical ED patients, with the greatest decrease observed in patients with intermediate severity of illness. Early ED downgrades also increased, but the difference was statistically significant only in the intermediate illness severity group.

Hospital variation in neonatal echocardiography among very preterm infants at US children's hospitals.

Estimate hospital variation in echocardiography (echo) among very preterm infants. Retrospective cohort study of very preterm (<32 weeks) infants discharged between 2012 and 2019 from US children's hospitals. Echo exposure was identified using daily billing, and hospital variation was estimated after adjustment for illness severity. Variation in very early echo use (<3 days of life) was compared to exposure to treatment of a patent ductus arteriosus (PDA), and other practice patterns. 27,498 subjects across 39 children's hospitals were included. Very early echo use had the greatest hospital variation (3-34%). Increasing very early echo use was not associated with PDA treatment (p = 0.93), but was associated with nitric oxide (p < 0.01) and vasoactive medications (p < 0.01). Hospital variation in echo use among preterm infants was greatest in the first few days of life and was associated with increasing nitric oxide and vasoactive medication use. The impact of this variation on clinical outcomes is uncertain and warrants further investigation.

Outcomes of Prolonged ICU Stay for Patients Undergoing Cardiac Surgery in Australia and New Zealand

To determine the effect of intensive care unit (ICU) length of stay (LOS) on hospital mortality and non-home discharge for patients undergoing cardiac surgery over a 16-year period in Australia and New Zealand. A retrospective, multicenter cohort study covering the period January 1, 2004 to December 31, 2019. One hundred one hospitals in Australia and New Zealand that submitted data to the Australia New Zealand Intensive Care Society Adult Patient Database. Adult patients (aged >18) who underwent coronary artery bypass grafting, valve surgery, or combined valve+coronary artery surgery. None. The authors analyzed 252,948 cardiac surgical patients from 101 hospitals, with a median age of 68.3 years (IQR 60-75.5), of whom 74.2% (187,632 of 252,948) were male patients. A U-shaped relationship was observed between ICU LOS and hospital mortality, with significantly elevated mortality at short (<20 hours) and long (>5 days) ICU LOS, which persisted after adjustment for illness severity and across clinically important subgroups (odds ratio for mortality with ICU LOS >5 days=3.21, 95% CI 2.88-3.58, p < 0.001). Prolonged duration of ICU LOS after cardiac surgery is associated with increased hospital mortality in a U-shaped relationship. An ICU LOS >5 days should be considered a meaningful definition for prolonged ICU stay after cardiac surgery.

The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest

Research questionGiven the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival? MethodsObservational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival. ResultsHospital survival was decreased with higher PaO2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume. ConclusionLower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.

The Use and Duration of Preintubation Respiratory Support Is Associated With Increased Mortality in Immunocompromised Children With Acute Respiratory Failure.

To determine the association between preintubation respiratory support and outcomes in patients with acute respiratory failure and to determine the impact of immunocompromised (IC) diagnoses on outcomes after adjustment for illness severity. Retrospective multicenter cohort study. Eighty-two centers in the Virtual Pediatric Systems database. Children 1 month to 17 years old intubated in the PICU who received invasive mechanical ventilation (IMV) for greater than or equal to 24 hours. None. High-flow nasal cannula (HFNC) or noninvasive positive-pressure ventilation (NIPPV) or both were used prior to intubation in 1,825 (34%) of 5,348 PICU intubations across 82 centers. When stratified by IC status, 50% of patients had no IC diagnosis, whereas 41% were IC without prior hematopoietic cell transplant (HCT) and 9% had prior HCT. Compared with patients intubated without prior support, preintubation exposure to HFNC (adjusted odds ratio [aOR], 1.33; 95% CI, 1.10-1.62) or NIPPV (aOR, 1.44; 95% CI, 1.20-1.74) was associated with increased odds of PICU mortality. Within subgroups of IC status, preintubation respiratory support was associated with increased odds of PICU mortality in IC patients (HFNC: aOR, 1.50; 95% CI, 1.11-2.03; NIPPV: aOR, 1.76; 95% CI, 1.31-2.35) and HCT patients (HFNC: aOR, 1.75; 95% CI, 1.07-2.86; NIPPV: aOR, 1.85; 95% CI, 1.12-3.02) compared with IC/HCT patients intubated without prior respiratory support. Preintubation exposure to HFNC/NIPPV was not associated with mortality in patients without an IC diagnosis. Duration of HFNC/NIPPV greater than 6 hours was associated with increased mortality in IC HCT patients (HFNC: aOR, 2.41; 95% CI, 1.05-5.55; NIPPV: aOR, 2.53; 95% CI, 1.04-6.15) and patients compared HCT patients with less than 6-hour HFNC/NIPPV exposure. After adjustment for patient and center characteristics, both preintubation HFNC/NIPPV use (median, 15%; range, 0-63%) and PICU mortality varied by center. In IC pediatric patients, preintubation exposure to HFNC and/or NIPPV is associated with increased odds of PICU mortality, independent of illness severity. Longer duration of exposure to HFNC/NIPPV prior to IMV is associated with increased mortality in HCT patients.

Impact of obesity on intensive care outcomes in patients with COVID-19 in Sweden-A cohort study.

BackgroundPrevious studies have shown that a high body mass index (BMI) is a risk factor for severe COVID-19. The aim of the present study was to assess whether a high BMI affects the risk of death or prolonged length of stay (LOS) in patients with COVID-19 during intensive care in Sweden.Methods and findingsIn this observational, register-based study, we included patients with COVID-19 from the Swedish Intensive Care Registry admitted to intensive care units (ICUs) in Sweden. Outcomes assessed were death during intensive care and ICU LOS ≥14 days. We used logistic regression models to evaluate the association (odds ratio [OR] and 95% confidence interval [CI]) between BMI and the outcomes. Valid weight and height information could be retrieved in 1,649 patients (1,227 (74.4%) males) with COVID-19. We found a significant association between BMI and the risk of the composite outcome death or LOS ≥14 days in survivors (OR per standard deviation [SD] increase 1.30, 95%CI 1.16–1.44, adjusted for sex, age and comorbidities), and this association remained after further adjustment for severity of illness (simplified acute physiology score; SAPS3) at ICU admission (OR 1.30 per SD, 95%CI 1.17–1.45). Individuals with a BMI ≥ 35 kg/m2 had a doubled risk of the composite outcome. A high BMI was also associated with death during intensive care and a prolonged LOS in survivors assessed as separate outcomes.The main limitations were the restriction to the first wave of the pandemic, and the lack of information on socioeconomic status as well as smoking.ConclusionsIn this large cohort of Swedish ICU patients with COVID-19, a high BMI was associated with increasing risk of death and prolonged length of stay in the ICU. Based on our findings, we suggest that individuals with obesity should be more closely monitored when hospitalized for COVID-19.

Alcohol misuse and critical care admissions in the Northern Territory.

The Northern Territory (NT) has a long history of heavy alcohol consumption with a correspondingly high attributable morbidity and mortality. To describe the number of admissions to intensive care associated with alcohol misuse. This is a prospective case-control study including all admissions to NT intensive care units (ICU) between 1 July 2018 and 30 June 2019. Characteristics and outcomes of patients who had an admission associated with alcohol misuse (a composite measure of acute and/or chronic misuse) were compared to those who did not. Primary outcome was the number of admissions associated with alcohol misuse. Secondary outcomes included measures of resource use (length of stay (LoS), need for mechanical ventilation) and mortality adjusted for illness severity. Over the sampling period there were 1664 admissions. After exclusions, 1471 admissions were analysed, of which 307 (21%) were associated with alcohol misuse. Acute or chronic misuse was associated with 3.7% and 12.1% of admissions respectively, while 5.1% met criteria for both. Admissions associated with alcohol misuse more frequently required ventilation (38.4% vs 20.7%, P < 0.01) and had longer ICU (2.8 vs 2.1 days, P < 0.01) and hospital LoS (9.1 vs 7.1 days, P < 0.01). There was no difference in hospital mortality (7.2% vs 7.7%, P = 0.94), even after adjustment for illness severity, hospital and diagnostic category. Alcohol misuse is associated with a substantial number of critical care admissions and consumes considerable acute care resources. Further policy directed at harm minimisation and epidemiological work at jurisdictional and national level is necessary.

Routine Frailty Screening in Critical Illness: A Population-Based Cohort Study in Australia and New Zealand

Frailty is associated with poor outcomes in critical illness. However, it is unclear whether frailty screening on admission to the ICU can be conducted routinely at the population level and whether it has prognostic importance. Can population-scale frailty screening with the Clinical Frailty Scale (CFS) be implemented for critically ill adults in Australia and New Zealand (ANZ) and can it identify patients at risk of negative outcomes? We conducted a binational prospective cohort study of critically ill adult patients admitted between July 1, 2018, and June 30, 2020, in 175 ICUs in ANZ. We classified frailty with the CFS on admission to the ICU. The primary outcome was in-hospital mortality; secondary outcomes were length of stay (LOS), discharge destination, complications (delirium, pressure injury), and duration of survival. We included 234,568 critically ill patients; 45,245 (19%) were diagnosed as living with frailty before ICU admission. Patients with vswithout frailty had higher in-hospital mortality (16%vs5%; P< .001), delirium (10%vs4%; P< .001), longer LOS in the ICU and hospital, and increased new chronic care discharge (3%vs1%; P< .001), with worse outcomes associated with increasing CFS category. Of patients with very severe frailty (CFS score, 8), 39%died in hospital vs2%of very fit patients (CFS score, 1; multivariate categorical CFS score, 8 [reference, 1]; OR, 7.83 [95%CI, 6.39-9.59]; P< .001). After adjustment for illness severity, frailty remained highly significantly predictive of mortality, including among patients younger than 50 years, with improvement in the area under the receiver operating characteristic curve of the Acute Physiology and Chronic Health Evaluation III-j score to 0.882 (95%CI, 0.879-0.885) from 0.868 (95%CI, 0.866-0.871) with the addition of frailty (P< .001). Large-scale population screening for frailty degree in critical illness was possible and prognostically important, with greater frailty (especially CFS score of≥ 6) associated with worse outcomes, including among younger patients.

Critical care resource use associated with tourism in Central Australia.

Tourism to regional and remote Australia is increasing. Its impact on regional critical care services is incompletely understood. We describe tourist admissions and their impact on critical care resources relative to the local population. Single-centre retrospective study using prospectively collected data from January 2009 to December 2018. Australian regional intensive care unit. All critical care admissions for patients aged over 18years for whom postcode data were available were included. Primary outcome was hospital mortality. Secondary outcomes examined resource use (intensive care unit and hospital length of stay, mechanical ventilation, interhospital transfer) and admission diagnosis. Tourists comprise 6.1% of critical care admissions, occupying 5.7% of intensive care unit bed days. They were less likely to be Indigenous (6.3% vs 72.7%), but older (61.5 vs 49.2years) and male (65.4% vs 52.6%). They were more frequently admitted following acute myocardial infarction (14.2% vs 8.9%) or trauma (20.0% vs 5.0%). There was no difference in hospital mortality (2.9% vs 4.0%) or intensive care unit mortality (2.4% vs 1.8%); however, tourists were more than twice as likely to require interhospital transfer (31.7% vs 14.0%). These findings persisted after adjustment for illness severity. Tourists are an appreciable caseload of this regional intensive care unit and are more likely to require interhospital transfer. There was no difference in mortality. Further research is required across regional and rural Australia to better understand the epidemiology and impact of tourism on critical care resources, and the economic implications of becoming unwell in a regional area.

Outcomes Associated With Norepinephrine Use Among Cardiac Intensive Care Unit Patients with Severe Shock.

Recent data suggests improved outcomes among cardiac intensive care unit (CICU) patients treated with norepinephrine, especially patients with severe shock. We aimed to describe the association between norepinephrine and mortality in CICU patients with severe shock, defined as those requiring high-dose vasopressors (HDV). We retrospectively evaluated Mayo Clinic CICU patients treated with vasopressors from 2007 to 2015. HDV was defined as a peak Cumulative Vasopressor Index of four for any vasopressor. Peak norepinephrine equivalent (NEE) dose was used to compare vasopressor doses. Multivariable logistic regression was used to determine predictors of hospital mortality. We included 2,090 patients with a median age of 69 years (IQR 59-78), including 35% females; 44% of patients received HDV. Hospital mortality was higher among patients receiving HDV (42% vs. 16%, unadjusted OR 3.87, 95% CI 3.16-4.75, P < 0.01). On multivariable analysis in HDV patients, hospital mortality increased with rising peak NEE (adjusted OR 1.02 per 0.01 mcg/kg/min, 95% CI 1.01-1.02, P < 0.01) and the use of NE was associated with lower hospital mortality (adjusted OR 0.46, 95% CI 0.31-0.72, P < 0.01). After adjustment for illness severity, peak NEE and norepinephrine use were not associated with mortality among patients who did not require HDV. Mortality is high among CICU patients requiring HDV, and rises with increasing vasopressor requirements. Use of NE was associated with lower mortality among patients requiring HDV, but not among those without HDV, implying that patients with more severe shock may benefit from preferential use of NE.

O037 / #606: NON-INVASIVE VENTILATION PRACTICE FOR PRIMARY RESPIRATORY MANAGEMENT IN THE PEDIATRIC INTENSIVE CARE UNITS: AN INTERNATIONAL STUDY

Aims & Objectives: To describe current practices and outcomes of Non-Invasive Ventilation (NIV) in PICUs internationally. Methods: IRB approved point prevalence study over 10 study weeks at 52 PICUs in 12 countries. Children were included if NIV was newly initiated on screening days, including high flow nasal cannula [HFNC: > 3LPM (Term / <1 year), > 4LPM (1-3 years), or >5LPM (>3 years)], continuous (CPAP) or bilevel positive airway pressure (BiPAP), or other NIV mode. We excluded post-operative cardiac surgery, post-extubation, and home NIV. The risk factor analysis used mixed effects logistic regression with stepwise addition/deletion (retention cutoff: p=0.15) Results: Of 15,310 patients screened, 695 met inclusion criteria, including 472 (68%) HFNC, 158 (23%) BiPAP, 62 (9%) CPAP, and 3 other modes. Median age was 15.4 months (IQR: 5.1-63.3). Main NIV indications were acute hypoxemia (51%) and respiratory distress (27%). NIV interface was nasal cannula 399 (58%), nasal mask/prongs 111 (16%), bucco-nasal mask 18 (3%), full-face mask 154 (22%), or other 3 (0.4%). NIV duration was 2.1 days (1-4). NIV failure (endotracheal intubation) occurred in 18.6% cases, 69.8% of them before 48h of NIV (Figure). After adjustment for severity of illness, risk factors for NIV failure included meeting at-risk criteria for Pediatric Acute Respiratory Distress Syndrome (p=0.02) and exposure to parenteral nutrition (p=<0.001). Factors predictive of NIV success were respiratory admission category (p=0.001) and exposure to enteral nutrition (p=0.001).Conclusions: NIV is frequently used in PICUs, with heterogenous practice. NIV failure occurs in 18.6% cases, most frequently within the first 48hrs

The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study

BackgroundInfectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges. MethodsAfter the installation of advanced air purification technology, 3 resultant air purification “zones” were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission. ResultsThe study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5–87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%). ConclusionPatients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.

Examining the association between triage streamed treatment location and time to appropriate antibiotics in emergency department patients with septic shock.

Early recognition and treatment for sepsis is critical in improving patient outcomes. The present study sought to examine whether triage location was associated with time to appropriate antibiotics in a cohort of ED patients with septic shock. Septic shock patients were identified from a database of ED patients admitted with infection. Demographic, clinical and outcome data were reported by triage location. Time to event analyses sought to identify the association between triage location and time to appropriate antibiotic. Secondary outcome variables included ED and hospital length of stay (LOS), 30-day mortality, and ICU admission. Time to appropriate antibiotic administration was longer for those patients triaged to lower acuity (242 min) compared to higher acuity (98 min, P < 0.01) locations. After adjustment for severity of illness, hospital LOS, ED LOS and 30-day mortality were similar regardless of the triaged location. Admission to ICU was lower for patients triaged to lower (7.3%) compared to higher (47.3%) acuity treatment locations. We identified a sub-group of septic shock patients triaged to a lower acuity treatment location who received significant delays to antibiotics. This research area deserves closer examination to potentially recognise septic shock earlier in the continuum.

Association between race/ethnicity, illness severity, and mortality in children undergoing cardiac surgery

ObjectivePrior studies demonstrate an association between nonwhite race/ethnicity, insurance status, and mortality after pediatric congenital heart surgery. The influence of severity of illness on that association is unknown. We examined the relationship between race/ethnicity, severity of illness, and mortality in congenital cardiac surgery, and whether severity of illness is a mechanism by which nonwhite patients experience increased surgical mortality. MethodsWe performed a retrospective cohort study of children younger than age 18 years old undergoing cardiac surgery admitted to the intensive care unit (n = 40,545) between 2009 and 2016 from the Virtual Pediatric Systems (VPS, LLC, Los Angeles, Calif) database. Multivariate regression models were constructed to examine the role of severity of illness as a mediator between race/ethnicity and mortality in children undergoing cardiac surgery. ResultsIn multivariate models examining severity of illness scores, African-American patients had statistically significant higher severity of illness scores when compared with their white counterparts. In multivariate models of intensive care unit mortality after adjustment for covariates, African-American patients had a higher odds of postoperative mortality (odds ratio, 1.40, 95% confidence interval, 1.04-1.89) when compared with white children. This increased odds of mortality was mediated through higher severity of illness, because adjustment for severity of illness removed this survival disadvantage for black patients. ConclusionsAlthough African-American children undergoing cardiac surgery had higher postoperative mortality, this survival difference appears to be mediated via severity of illness. Preoperative and intraoperative factors may be drivers for this survival disparity.

Red Blood Cell Transfusion After Stage I Palliation Is Associated With Worse Clinical Outcomes.

BackgroundPacked red blood cell transfusion may improve oxygen content in single‐ventricle neonates, but its effect on clinical outcomes after Stage 1 palliation is unknown.Methods and ResultsRetrospective multicenter analysis of packed red blood cell transfusion exposures in neonates after Stage 1 palliation, excluding those with intraoperative mortality or need for extracorporeal membrane oxygenation. Transfusion practice variability was assessed, and multivariable regression used to identify transfusion risk factors. After propensity score adjustment for severity of illness, clinical outcomes were compared between transfused and nontransfused subjects. Of 396 subjects, 323 (82%) received 930 postoperative red blood cell transfusions. Packed red blood cell volume (median 9–42 mL/kg [P<0.0001]), donor exposures (1–2 [P<0.0001]), transfusion number (1–3 [P<0.0001]), and pretransfusion hemoglobin (12.1–13 g/dL, P=0.0049) varied between sites. Cyanosis (P=0.02), chest tube output (P=0.0003), and delayed sternal closure (P=0.0033) increased transfusion risk. Transfusion was associated with prolonged mechanical ventilation (6 [interquartile range 4, 12] versus 3 [1, 5] days, P=0.02) and intensive care unit stay (19 [12, 33] versus 9 [6, 19] days, P=0.016). When stratified by number of transfusions (0, 1, or >1), duration of mechanical ventilation (3 [1, 5] versus 4 [3, 6] versus 9 [5, 16] days [P<0.0001]) and intensive care unit stay (9 [6, 19] versus 13 [8, 25] versus 21 [13, 38] days [P<0.0001]) increased for those transfused more than once. Most subjects who died were transfused, though the association with mortality was not significant.ConclusionsPacked red blood cell transfusion after Stage 1 palliation is common, and transfusion practice is variable. Transfusion is a significant predictor of longer intensive care unit stay and mechanical ventilation. Further studies to define evidence‐based transfusion thresholds are warranted.

Temporal Trends and Clinical Outcomes Associated with Vasopressor and Inotrope Use in The Cardiac Intensive Care Unit.

The use of norepinephrine may be associated with better outcomes in some patients with shock. We sought to determine whether norepinephrine was associated with lower mortality in unselected cardiac intensive care unit (CICU) patients compared with other vasopressors, and whether patterns of vasopressor and inotrope usage in the CICU have changed over time. We retrospectively evaluated consecutive adult patients admitted to a tertiary care hospital CICU from January 1, 2007 to December 31, 2015. Vasoactive drug doses were quantified using the peak Vasoactive-Inotropic Score (VIS). Temporal trends were assessed using the Cochran-Armitage trends test and multivariable logistic regression was used to determine predictors of hospital mortality. We included 10,004 patients with a mean age of 67 ± 15 years; vasoactive drugs were used in 2,468 (24.7%) patients. Use of norepinephrine increased over time, whereas dopamine utilization decreased (P < 0.001 for trends). After adjustment for illness severity and other variables, the peak VIS was a predictor of hospital mortality across the entire population (unit odds ratio [OR] 1.013, 95% confidence interval [CI], 1.009-1.017, P < 0.001) and among patients receiving vasoactive drugs (OR 1.018, 95% CI, 1.013-1.022, P < 0.001). Among patients receiving vasoactive drugs, norepinephrine was associated with a lower risk of hospital mortality (OR 0.66, 95% CI, 0.49-0.90, P = 0.008) after adjustment for illness severity and peak VIS. Vasoactive drug use in CICU patients has a dose-dependent association with short-term mortality. Use of norepinephrine in CICU patients is associated with decreased odds of death when compared with other vasoactive drugs.

Polypharmacy in HIV: recent insights and future directions.

Update findings regarding polypharmacy among people with HIV (PWH) and consider what research is most needed. Among PWH, polypharmacy is common, occurs in middle age, and is predominantly driven by nonantiretroviral (ARV) medications. Many studies have demonstrated strong associations between polypharmacy and receipt of potentially inappropriate medications (PIMS), but few have considered actual adverse events. Falls, delirium, pneumonia, hospitalization, and mortality are associated with polypharmacy among PWH and risks remain after adjustment for severity of illness. Polypharmacy is a growing problem and mechanisms of injury likely include potentially inappropriate medications, total drug burden, known pairwise drug interactions, higher level drug interactions, drug--gene interactions, and drug--substance use interactions (alcohol, extra-medical prescription medication, and drug use). Before we can effectively design interventions, we need to use observational data to gain a better understanding of the modifiable mechanisms of injury. As sicker individuals take more medications, analyses must account for severity of illness. As self-report of substance use may be inaccurate, direct biomarkers, such as phosphatidylethanol (PEth) for alcohol are needed. Large samples including electronic health records, genetics, accurate measures of substance use, and state of the art statistical and artificial intelligence techniques are needed to advance our understanding and inform clinical management of polypharmacy in PWH.