Intensive Care Unit Bed Availability Research Articles

Critical care services in Bagmati province of Nepal: A cross sectional survey

Background This study aimed to assess the current status of critical care services in 13 districts of Bagmati Province in Nepal, with a focus on access, infrastructure, human resources, and intensive care unit (ICU) services. Methods A cross-sectional survey was conducted among healthcare workers employed in 87 hospitals having medical/surgical ICUs across Bagmati Province. Data were collected through structured questionnaires administered via face-to-face and telephone interviews. Descriptive analysis was used for data analysis, involving frequencies and percentages. Results From 87 hospitals, a total of 123 ICUs were identified in the province, providing 1167 beds and 615 functioning ventilators. The average ICU bed availability per 100,000 population was 19, ranging from 3.6 in Makwanpur to 33.9 in Kathmandu. Out of 13 districts, 95% of beds were concentrated in just four districts, while six had no ICU facilities. Of the available facilities, 69.9% were owned by private entities. One-to-one nurse-to-ventilated bed ratio was maintained by 63.4% of ICUs during daytime, and 62.6% at nighttime. Furthermore, 74.8% of ICUs had consultants trained in critical care medicine. While essential equipment availability was higher in Bagmati province, gaps existed in the availability of oxygen plants and isolation rooms. Similarly, many ICUs offered continuous medical education and cardiopulmonary resuscitation (CPR) training, but improvements were necessary in clinical audits, antibiotic stewardship programs, and research engagement. Conclusions Disparities in critical care resources were evident across districts in Bagmati Province, highlighting the need for a balanced and decentralized approach to ensure equitable access to care. Although there were disparities, numerous ICUs were effectively carrying out multiple critical care procedures. This study suggests conducting a nationwide mapping of ICU resources, prioritizing infrastructure development, optimizing resource allocation, and establishing national protocols.

Survival and predictors of adult patients admitted to intensive care unit in Yekatit 12 Hospitals, Addis Ababa, Ethiopia.

Background In hospitals, one of the main service components is an intensive care unit (ICU) that provides aggressive therapy for critically ill and high-risk patients. The availability of ICU beds has been progressively growing in Africa, but many studies show that the ICU mortality rate is very high. However, many of those studies are only descriptive and focus on medical or surgical patients. This study includes patients from all wards except pediatrics. Methods A retrospective cohort study was carried out in the intensive care unit at Yekatit 12 Hospital, Ethiopia. The Kaplan-Meier method was used to describe the probability of survival in ICU stay. The Cox proportional hazard model was used for the multivariate analysis to determine the possible associations of predictor variables and to obtain the adjusted hazard ratios. A statistically significant association was declared at p <0.05 with a 95% confidence interval. Results The survival rate was 69.7% with a mortality rate of 30.3%. This study confirmed that the risk of mortality among ICU patients was the education status of the study participants, attending primary education was twice that of patients attending higher education with an adjusted hazard ratio (AHR) (AHR=2.097, 95% CI:1.081,4.067). Patients admitted to ICU because of shock were more than four times at risk of death compared to other causes (AHR= 4.51, 95% CI: 2.41, 8.45). The risk of mortality among ICU patients admitted because of brain injury was more than two times compared to other patients (AHR=2.77, 95% CI: 1.18, 6.47). Patients with respiratory failure were more than two times at risk of mortality (AHR=2.42, 95% CI: 1.19, 4.87). Conclusions The survival of ICU patients was low. Formal education level, patients admitted for shock, brain injury, and respiratory failure were found to be significantly associated with the survival of ICU patients.

Survival and predictors of adult patients admitted to intensive care unit in Yekatit 12 Hospitals, Addis Ababa, Ethiopia.

Background In hospitals, one of the main service components is an intensive care unit (ICU) that provides aggressive therapy for critically ill and high-risk patients. The availability of ICU beds has been progressively growing in Africa, but many studies show that the ICU mortality rate is very high. However, many of those studies are only descriptive and focus on medical or surgical patients. This study includes patients from all wards except pediatrics. Methods A retrospective cohort study was carried out in the intensive care unit at Yekatit 12 Hospital, Ethiopia. The Kaplan-Meier method was used to describe the probability of survival in ICU stay. The Cox proportional hazard model was used for the multivariate analysis to determine the possible associations of predictor variables and to obtain the adjusted hazard ratios. A statistically significant association was declared at p <0.05 with a 95% confidence interval. Results The survival rate was 69.7% with a mortality rate of 30.3%. This study confirmed that the risk of mortality among ICU patients was the education status of the study participants, attending primary education was twice that of patients attending higher education with an adjusted hazard ratio (AHR) (AHR=2.097, 95% CI:1.081,4.067). Patients admitted to ICU because of shock were more than four times at risk of death compared to other causes (AHR= 4.51, 95% CI: 2.41, 8.45). The risk of mortality among ICU patients admitted because of brain injury was more than two times compared to other patients (AHR=2.77, 95% CI: 1.18, 6.47). Patients with respiratory failure were more than two times at risk of mortality (AHR=2.42, 95% CI: 1.19, 4.87). Conclusions The survival of ICU patients was low. Formal education level, patients admitted for shock, brain injury, and respiratory failure were found to be significantly associated with the survival of ICU patients.

Critical care services in Bagmati province of Nepal: A cross sectional survey

Background This study aimed to assess the current status of critical care services in 13 districts of Bagmati Province in Nepal, with a focus on access, infrastructure, human resources, and intensive care unit (ICU) services. Methods A cross-sectional survey was conducted among healthcare workers employed in 87 mixed medical/surgical ICUs across Bagmati Province. Data were collected through structured questionnaires administered via face-to-face and telephone interviews. Descriptive analysis was used for data analysis, involving frequencies and percentages. Results A total of 123 ICUs were identified in the province, providing 1167 beds and 615 functioning ventilators. The average ICU bed availability per 100,000 population was 19, ranging from 3.6 in Makwanpur to 33.9 in Kathmandu. Out of 13 districts, 95% of beds were concentrated in just four districts, while six had no ICU facilities. Of the available facilities, 69.9% were owned by private entities. One-to-one nurse-to-ventilated bed ratio was maintained by 63.4% of ICUs during daytime, and 62.6% at nighttime. Furthermore, 74.8% of ICUs had consultants trained in critical care medicine. While essential equipment availability was higher in Bagmati province, gaps existed in the availability of oxygen plants and isolation rooms. Similarly, many ICUs offered continuous medical education and cardiopulmonary resuscitation (CPR) training, but improvements were necessary in clinical audits, antibiotic stewardship programs, and research engagement. Conclusions Disparities in critical care resources were evident across districts in Bagmati Province, highlighting the need for a balanced and decentralized approach to ensure equitable access to care. Although there were disparities, numerous ICUs were effectively carrying out multiple critical care procedures. This study suggests conducting a nationwide mapping of ICU resources, prioritizing infrastructure development, optimizing resource allocation, and establishing national protocols.

An explainable decision model based on extended belief-rule-based systems to predict admission to the intensive care unit during COVID-19 breakout

Given the shortage of intensive care units (ICUs) due to the coronavirus disease (COVID-19), a prediction model is essential in ensuring the availability of ICU beds. However, several challenges, such as the importance of distinguishing indicators, efficiency of ICU admission records, and the explainability and effectiveness of the prediction model, hinder the effective prediction of ICU admissions. To mitigate these challenges, an explainable decision model that uses the extended belief rule-based system is introduced to predict ICU admission. First, an indicator extraction model is proposed to measure the importance of the various indicators and obtain representative indicators. Second, a Charnes, Cooper, and Rhodes (CCR) model is constructed to measure the efficiencies of the belief rules to achieve the compact structure of an extended belief rule base. Third, a new extended belief rule-based model, optimized by parameter optimization and domain division-based rule reduction, is developed to predict ICU admission. These procedures enable the explainable decision model to adapt to big data situation, offer explanations and realize high efficiency. Finally, a case study of ICU admission during a COVID-19 outbreak is conducted to demonstrate the implementation and effectiveness of the proposed model in a comparative analysis.

Causes and Outcomes of Intensive Care Admission Refusals: A Retrospective Audit from a Rural Teaching Hospital in Eastern Cape, South Africa.

(1) Background: Patients who deserve intensive care unit (ICU) admission may be denied due to a lack of resources, complicating ICU triage decisions for intensive care unit (ICU) clinicians. Among the resources that may be unavailable are trained personnel and monitored beds. In South Africa, the distribution of healthcare resources is reflected in the availability of ICU beds, with more ICU beds available in more affluent areas. Data on ICU refusal rates, reasons for refusal, patient characteristics, and outcomes are scarce in resource-constrained rural settings. Hence, this study sheds light on the ICU refusal rates, reasons for refusal, characteristics, and outcomes of refused patients at NMAH. (2) Methods: This was a three-month retrospective cross-sectional record review of refused and admitted patients from January to March 2022. COVID-19 patients and those younger than 13 years old were excluded. Refusal rates, reasons for refusal, characteristics, and outcomes of refused patients were analysed quantitatively using SPSS VS 20 software. Reasons for refusal were categorised as "too well", "too sick", and "suitable for admission but no resources". (3) Results: A total of 135 patients were discussed for ICU admission at NMAH during the study period; 73 (54.07%) were refused admission, and 62 (45.92%) were admitted. Being considered too sick to benefit from ICU was the most common reason for refusal (53.23%). Too well and no resources contributed 27.42% and 19.35%, respectively. Patients with poor functional status, comorbidities, medical diagnoses, and those referred from the ward or accident and emergency unit rather than the operating room were more likely to be refused ICU admission. Refused patients had a seven-day mortality rate of 47%. (4) Conclusions and recommendations: The study found an unmet need for critical care services at our institution, as well as a need for tools to help clinicians make objective triage decisions for critically ill patients. Therefore, the study suggests a need to improve the quality of services provided outside of the ICU, particularly for patients who were refused ICU admission, to improve their outcomes.

Association between the timing of ICU admission and mortality in patients with hospital-onset sepsis: a nationwide prospective cohort study

BackgroundBased on sparse evidence, the current Surviving Sepsis Campaign guideline suggests that critically ill patients with sepsis be admitted to the intensive care unit (ICU) within 6 h. However, limited ICU bed availability often makes immediate transfer difficult, and it is unclear whether all patients will benefit from early admission to the ICU. Therefore, the purpose of this study was to determine the association between the timing of ICU admission and mortality in patients with hospital-onset sepsis.MethodsThis nationwide prospective cohort study analyzed patients with hospital-onset sepsis admitted to the ICUs of 19 tertiary hospitals between September 2019 and December 2020. ICU admission was classified as either early (within 6 h) or delayed (beyond 6 h). The primary outcome of in-hospital mortality was compared using logistic regression adjusted for key prognostic factors in the unmatched and 1:1 propensity-score-matched cohorts. Subgroup and interaction analyses assessed whether in-hospital mortality varied according to baseline characteristics.ResultsA total of 470 and 286 patients were included in the early and delayed admission groups, respectively. Early admission to the ICU did not significantly result in lower in-hospital mortality in both the unmatched (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 0.99–1.85) and matched cohorts (aOR, 1.38; 95% CI, 0.94–2.02). Subgroup analyses showed that patients with increasing lactate levels (aOR, 2.10; 95% CI, 1.37–3.23; P for interaction = 0.003), septic shock (aOR, 2.06; 95% CI, 1.31–3.22; P for interaction = 0.019), and those who needed mechanical ventilation (aOR, 1.92; 95% CI, 1.24–2.96; P for interaction = 0.027) or vasopressor support (aOR, 1.69; 95% CI, 1.17–2.44; P for interaction = 0.042) on the day of ICU admission had a higher risk of mortality with delayed admission.ConclusionsAmong patients with hospital-onset sepsis, in-hospital mortality did not differ significantly between those with early and delayed ICU admission. However, as early intensive care may benefit those with increasing lactate levels, septic shock, and those who require vasopressors or ventilatory support, admission to the ICU within 6 h should be considered for these subsets of patients.

412 A Protocol for Reducing Intensive Care Utilization After Craniotomy: A Three-Year Assessment

INTRODUCTION: Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the “Non-Intensive CarE” (NICE) protocol to identify craniotomy patients that did not require postoperative ICU care. METHODS: Our institution’s electronic medical record (EMR) was queried to identify craniotomies prior to protocol deployment (May 2014-May 2018), and after deployment (May 2018-December 2021). Patients are considered for the protocol if they are having an elective craniotomy for select procedures (e.g. microvascular decompressions, extra-axial tumor resection), are under age of 65, have no history of coagulopathy, and have no other medical contraindications. Reason for readmission or reoperation among NICE protocol patients was collected via chart review. The primary endpoints were average POLS and ICU utilization; secondary endpoints included readmission, reoperation, and postoperative complications rates. Endpoints were compared among pre- and post-protocol cohorts. RESULTS: 4,837 craniotomies were performed from May 2014-December 2021 (2,302 pre-protocol, 2,535 post-protocol). 21% percent of post-protocol craniotomies were enrolled in the NICE protocol. After protocol deployment, overall POLS decreased from 4.0 to 3.5 days (p = 0.0031), which was driven by deceased POLS among protocol patients (average 2.4 days).ICU utilization decreased from 57% of patients to 42% (p < 0.0001), generating ∼$760,000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within thirty days; none could have been prevented through ICU stay. CONCLUSIONS: The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022.

Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

A Protocol for Reducing Intensive Care Utilization After Craniotomy: A 3-Year Assessment.

Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the "Non-Intensive CarE" (NICE) protocol to identify craniotomy patients who did not require postoperative ICU care. To determine the longitudinal impact of the NICE protocol on postoperative length of stay (LOS), ICU utilization, readmissions, and complications. In this retrospective cohort study, our institution's electronic medical record was queried to identify craniotomies before protocol deployment (May 2014-May 2018) and after deployment (May 2018-December 2021). The primary end points were average postoperative LOS and ICU utilization; secondary end points included readmissions, reoperation, and postoperative complications rate. End points were compared between pre- and postintervention cohorts. Four thousand eight hundred thirty-seven craniotomies were performed from May 2014 to December 2021 (2302 preprotocol and 2535 postprotocol). Twenty-one percent of postprotocol craniotomies were enrolled in the NICE protocol. After protocol deployment, the overall postoperative LOS decreased from 4.0 to 3.5 days ( P = .0031), which was driven by deceased postoperative LOS among protocol patients (average 2.4 days). ICU utilization decreased from 57% of patients to 42% ( P < .0001), generating ∼$760 000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within 30 days; none could have been prevented through ICU stay. The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

Examining need and capacity for the development of a pediatric liver transplantation program in Kenya.

In Africa, pediatric liver transplantation (PLT) is currently only performed in Egypt and South Africa, leaving those who require treatment in Kenya to travel abroad. The aim of this study was to determine whether sufficient capacity and need exists in Kenya to establish a safe and sustainable PLT program. A descriptive analysis of the intensive care unit (ICU) beds, surgical workforce, current hepatobiliary volume, and estimated prevalence of pediatric liver disease (PLD) was conducted across 17 hospitals in Kenya between July and September 2020. Data were collected from medical superintendents, directors of surgical departments, or nominated proxies at Kenyan Level 5 and 6 hospitals via a web-based survey. A total of 165 ICU beds were reported at 17 facilities, with 15 facilities reporting five or more beds. About 39% of general surgeons at responding hospitals performed hepatobiliary procedures, and 30% performed pediatric surgeries. Only 10% of surgeons had pediatric training. Over half (57%) of hospitals performed hepatobiliary procedures; at the maximum, 1-5 cases were performed per week including cholecystectomy to Kasai portoenterostomy and hepatectomy. Across 13 hospitals, there were an estimated 192-570 cases of PLD seen per month. The most common PLDs were hepatitis B, neonatal hepatitis, cirrhosis, and acute hepatic failure. Overall, two hospitals possessed the minimum workforce and resources to attempt PLT. In Kenya, ICU bed availability, pediatric surgical training, and hepatobiliary volume are limited. However, the high prevalence of PLD demonstrated a significant need for PLT across all Kenyan hospitals.

Comparing Neuro-COVID-19 between Waves Requires Clear Cohort Selection.

We read with interest the article by Sureshbabu et al. on a retrospective, single-center, observational study comparing first- and second-wave neurological manifestations of COVID-19.[1] A detailed questionnaire on co-morbidities, admission details, and clinical characteristics was applied to 1700 COVID-19 patients in the first and 1500 COVID-19 patients in the second wave.[1] The most common neurological manifestations of the second wave were headache, fatigue myalgia, dysgeusia, dysosmia, dizziness, encephalopathy, and stroke.[1] Dizziness, myalgia, headache, meningoencephalitis, occurred more commonly in the second wave than in the first wave. Cerebrovascular disease occurred less frequently in the second wave than in the first wave.[1] The mortality of COVID-19 patients with neurological involvement was higher in the second compared to the first wave.[1] The study is appealing but raises concerns that should be discussed. A limitation of the study is its retrospective design. The quality of the data depends heavily on the care and accuracy with which the data were collected and documented. Missing data can no longer be added. Confirmed diagnoses can no longer be corrected. Another limitation relates to the demarcation between first and second wave. There is no mention of how the end of the first wave and the beginning of the second wave was defined. It is therefore conceivable that an overlap occurred and some patients actually belong to the other group or vice versa. Another limitation of the study is that the waves were defined by a time criterion and not be the presence of a specific viral mutant. Different mutants of a virus variant with different pathogenicity and therefore different tropism for the central and peripheral nervous system can circulate during a single wave. Therefore, neither patients of the first nor the second wave represent a homogenous cohort and can therefore only be compared to a limited extent. Another limitation is that it remains unclear how the authors ruled out that neurological manifestations were not a manifestation of the infection but were actually side effects of the treatment the enrolled patients received to treat COVID-19. In particular, neuropathy and myopathy have been reported as side effects of commonly administered anti-COVID-19 drugs, such as colchicine, tocilizumab, prednisolone, or remdesivir.[2] Surprisingly, according to Table 1, the number of imaging examinations is very small. It is therefore conceivable that a number of cerebrovascular abnormalities may actually have been missed. Quite a few patients had to be transferred to the intensive care unit (ICU) (n = 127).[1] Because a stay in the ICU can be complicated by critical illness neuropathy/myopathy,[3] we should know how the authors ruled out that neuropathy or myopathy was actually a critical illness neuropathy/myopathy, but not due to the infection. Another limitation is that the cerebro-spinal fluid (CSF) was obviously not examined in any of the patients.[1] We should therefore know how meningo-encephalitis was diagnosed in the five meningo-encephalitis patients listed in Table 2. Was the diagnosis established just based on the imaging or the clinical picture? It is not comprehensible why a distinction was made between “visual impairment,” “smell and taste disorder,” and “altered sensorium.”[1] We should know which specific sense was altered in the 40 patients with altered sensorium. One second wave patient was diagnosed with cerebral vasculitis.[1] We should know what subtype of vasculitis was diagnosed and how. Has this particular patient had an intracranial artery biopsy or was the diagnosis suspected based on imaging criteria? An unaccounted explanation for the difference between wave one and wave two patients is the variable availability of medical resources over time. With progression of the pandemic, there may have been significant changes in health policy, the pathogenicity of virus variants, and the availability of hospital or ICU beds. Overall, the interesting study has some limitations and inconsistencies that call the results and their interpretation into question. Addressing these limitations could further strengthen and reinforce the statement of the study. Ethics approval Only secondary data were used. Availability of data All data are available from the corresponding author. Author contribution JF: design, literature search, discussion, first draft, critical comments, final approval. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Venous Sinus Stenting: Safety and Health Care Resource Evaluation for Optimal Recovery in an Evolving Health Care Environment

Increasing evidence supports the effectiveness of venous sinus stenting (VSS) with favorable outcomes, safety, and expenses compared with shunting for idiopathic intracranial hypertension. Yet, no evidence is available regarding optimal postoperative recovery, which has increasing importance with the burdens on health care imposed by the coronavirus disease 2019 pandemic. We examined adverse events and costs after VSS and propose an optimal recovery pathway to maximize patient safety and reduce stress on health care resources. A retrospective review was undertaken of elective VSS operations performed from May 2008 to August 2021 at a single institution. Primary data included hospital length of stay, intensive care unit (ICU) length of stay, adverse events, need for ICU interventions, and hospital costs. Fifty-three patients (98.1% female) met the inclusion criteria. Of these patients, 51 (96.2%) were discharged on postoperative day (POD) 1 and 2 patients were discharged on POD 2. Both patients discharged on POD 2 remained because of groin hematomas from femoral artery access. There were no major complications or care that required an ICU. Eight patients (15.1%) were lateralized to other ICUs or remained in a postanesthesia care unit because the neurosciences ICU was above capacity. Total estimated cost for initial recovery day in a neurosciences ICU room was $2361 versus $882 for a neurosurgery/neurology ward room. In our cohort, ward convalescence would save an estimated $79,866 for bed placement alone and increase ICU bed availability. Our findings reaffirm the safety of VSS. These patients should recover on a neurosurgery/neurology ward, which would save health care costs and increase ICU bed availability.

DOCTORS WITHOUT "BOARDERS": EFFECTS OF BOARDING MEDICAL ICU PATIENTS

DOCTORS WITHOUT "BOARDERS": EFFECTS OF BOARDING MEDICAL ICU PATIENTS

When Outcomes Diverge: Age and Cardiovascular Risk as Determinants of Mortality and ICU Admission in COVID-19.

Background: Hospital mortality and admission to the Intensive Care Unit (ICU) are markers of disease severity in COVID-19 patients. Cardiovascular co-morbidities are one of the main determinants of negative outcomes. In this study we investigated the impact of cardiovascular co-morbidities on mortality and admission to the ICU in first-wave COVID-19 patients. Methods: A multicenter, retrospective, cohort study. A total of 1077 patients were analyzed for mortality and ICU admission. Cardiovascular risk factors were explored as determinants of the outcomes after correction for other confounders. Results: In the multivariable model, after correction for age, only a history of heart failure remained independently associated (p = 0.0013) with mortality (hazard ratio 2.22, 95% confidence interval 1.37 to 3.62). Age showed a mortality risk increase of 8% per year (hazard ratio 1.08, 95% confidence interval 1.05 to 1.10, p = 0.001). The transition from ward to the ICU had, as a single determinant, the age, but in a reversed fashion (hazard ratio 0.96, 95% confidence interval 0.94 to 0.98, p = 0.0002). Conclusions: Once adjusted for the main determinant of mortality (age) heart failure only remained independently associated with mortality. Admission to the ICU was less likely for elderly patients. This may reflect the catastrophic impact of the first wave of COVID-19 pandemic in terms of ICU bed availability in Lombardy, leading to a selection process for ICU admission.

Ethical Management of COVID-19 Pandemic at a Neurological Hospital: The Ethicovid Report.

During the first wave of the coronavirus disease-2019 (COVID-19) pandemic, it was necessary to prepare for the possibility of triaging patients who could benefit from access to an intensive care unit (ICU). In our neuroscience institution, the challenge was to continue to manage usual neurological emergencies as well as the influx of COVID-19 patients. We report the experience of an ethical consulting unit to support care clinical decisions during the first wave of the pandemic (March 16 to April 30, 2020). Three objective evaluation criteria were defined: 2 of these criteria, patient's factors and general disease severity (Simplified Acute Physiology Score II), were common to all patients, and the third was the specific severity of the disease (neurological for brain injury, respiratory for COVID-19). Given our scarce resources, we used a high probability of a 3-month modified Rankin Scale ≤3 as the criterion for further resuscitation and management. A total of 295 patients were admitted during the first pandemic wave; 111 with COVID-19 and 184 with neurological emergencies. The ethical unit's expertise was sought for 75 clinical situations in 56 patients (35 COVID-19 and 21 neurological). Decisions were as follows: 11% no limitation on care, 5% expectant care with reassessment (maximum therapy to assess possible progress pending decision), 67% partial limitation (no intensification of care or no transfer to ICU), and 17% limitation of curative care. At no time did a lack of availability of ICU beds require the ethical unit to advise against admission to the ICU. Our ethical consulting unit allowed for collegial ethical decision-making in line with international recommendations. This model could be easily transferred to other triage situations, provided it is adapted to the local context.

No increase of device associated infections in German intensive care units during the start of the COVID-19 pandemic in 2020

BackgroundThe COVID-19 pandemic may have had a substantial impact on the incidence of device-associated healthcare-associated infections (HAI), in particular in intensive care units (ICU). A significant increase of HAI was reported by US hospitals when comparing incidence rates from 2019 and 2020. The objective of this study was to investigate the development of the most relevant device-associated HAI in German ICUs during the year 2020 as compared to 2019.MethodsWe utilized the data of the ICU component of the German National Reference Center for Surveillance of Nosocomial Infections (KISS = Krankenhaus-Infektions-Surveillance-System) for the period 2019–2020. We focused on central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated lower respiratory infections (VALRTI) and bloodstream infections associated with the use of Extracorporeal-Life-Support-Systems (ECLSABSI). Device use was defined as the number device days per 100 patient days; device-associated infection rates as the number of device-associated infections per 1000 device days. To compare the pooled means between the years and quarters we calculated rate ratios of device-associated infection rates with 95% confidence intervals by Poisson regression models.ResultsThe number of participating ICUs in the surveillance system decreased from 982 in 2019 to 921 in 2020 (6.2%). Device utilization rates increased significantly for central lines and ventilator use. VALRTI rates and CAUTI rates decreased in 2020 compared with 2019, however, no increase was shown for CLABSI or ECLSABSI. This result was also confirmed when the corresponding quarters per year were analyzed.ConclusionsThe lack of an increase in device-associated healthcare associated infections (HAI) in German ICUs may be due to the lower overall incidence of COVID-19 cases in Germany in 2020 compared with US, to a very high availability of ICU beds per 100,000 inhabitants compared with many other countries, and a change in the ICU patient mix due to numerous elective procedures that were postponed during the first two waves. The primary reason seems to be that only 7% of all ICU patients in Germany in 2020 were COVID-19 patients.

Outcomes and success of new tiered perinatal transfer policy within a tertiary level obstetric unit in Australia.

New South Wales Health introduced the new Tiered Networking Arrangements for Perinatal Care in New South Wales policy directive (TPN Policy), which defined key performance and quality indicators after implementation. This study aims to assess the success of the TPN Policy implementation in the Western Sydney TPN in accordance with key performance indicators. This is a retrospective cohort study of acute perinatal transfers within the Western Sydney TPN between 1 December 2019 to 31 December 2020. The primary outcome is compliance with objectives of the TPN Policy, as measured as an Aggregate Compliance Score comprising the five measures. Secondary outcomes include clinical, neonatal and logistics outcomes. There were 181 acute perinatal transfers within, into or out of the Western Sydney TPN between 1 December 2019 to 31 December 2020. There were 122 transfers within the network, 40 into the TPN and 19 were out of the TPN. All groups were at least partially compliant with the TPN Policy. No transfers in any of groups scored below three ('partially compliant'). A quarter of transfers gave birth within 24h of transfer. Over half of those who were transferred and admitted went on to give birth prior to discharge or transfer. Overall, the TPN Policy met its objectives after implementation in the Western Sydney TPN, while maintaining appropriate neonatal outcomes. All women arrived at an appropriate facility prior to giving birth, although the majority did not give birth within 24h. Neonatal intensive care unit bed availability is a key limitation to future improvement.

Skor risiko kejadian kardiovaskular mayor di rumah sakit pada sindroma koroner akut dengan elevasi segmen ST yang menjalani intervensi koroner perkutan primer

Background&#x0D; Reduction of major cardiovascular events (MACE) in ST elevation acute coronary syndrome (STE-ACS) patients has been achieved by primary percutaneous coronary intervention (PCI) strategy and intensive care management. However, the intensive care unit bed availability and cost remain a problem for those patients, and thus risk stratification using an objective risk score instrument is required.&#x0D; Aim&#x0D; To develop a risk score of in-hospital MACE for patients with STE-ACS underwent primary PCI.&#x0D; Methods&#x0D; A cohort study of 208 patients with STE-ACS undergoing primary PCI at the Dr. Kariadi General Hospital Semarang. Predictor analysis was carried out using bivariate Chi-Square test and multivariate logistic regression. The obtained independent predictors were then used as risk score variables. The quality of the risk score was tested by the Hosmer and Lemeshow calibration test and AUC ROC analysis for discrimination test.&#x0D; Results&#x0D; Seven out of 13 independent predictors, i.e. Killip class (OR 20,04, p=0,0001), age (OR 3,02, p=0,04), renal insufficiency (OR 9,48, p=0,007), infark related artery final TIMI flow (OR 11,57, p=0,001), admission systolic blood pressure (OR 3,04, p=0,025), duration of total ischaemic time (OR 3,14,p=0,032) and increase of blood glucose levels (OR 3,04, p=0,029) were fulfilled the criteria for risk scores of in-hospital MACE. The risk scores had a good quality with the Hosmer and Lemeshow calibration test&gt; 0,05 and ROC AUC 0,886 (95% CI, 0,827-0,944, p &lt;0,005).&#x0D; Conclusions&#x0D; A risk scoring modele consisting of 7 independent predictor variables i.e. Killip class, age, renal insufficiency, infark related artery final TIMI flow, admission systolic blood pressure, duration of total ischaemic time, and increase of blood glucose levels (KARIADI) has a good calibration and discrimination in predicting the risk of in-hospital MACE in patients with STE-ACS underwent primary PCI.&#x0D; Keywords&#x0D; Predictors of in-hospital MACE, primary PCI, ST-segment elevation acute coronary syndromes, risk score.

Profile of referrals to an intensive care unit from a regional hospital emergency centre in KwaZulu-Natal.

IntroductionThe objective was to describe the clinical characteristics, disease profile and outcome of patients referred from a regional hospital Emergency Centre (EC) to the Intensive Care Unit (ICU).MethodsA retrospective review was performed using data extracted from the Integrated Critical Care Electronic Database (iCED). Data were extracted from the database with respect to patient characteristics, Society of Critical Care Medicine (SCCM) grading, and outcome of the ICU referral. Modified early warning scores (MEWS) were calculated from EC referral data.ResultsThere were a total of 2187 referrals. Of these, 56.3% (1231/2187) were male. The mean age of referrals was 36 years. Of the referred patients, 41.5% (907/2187) were initially accepted for admission. A further 378 patients were accepted for admission after a follow up ICU review. Medical conditions accounted for the majority of patient referrals, followed by general surgery and trauma. Most patients initially accepted to ICU were classified as SCCM I and II and had a mean MEWS of 4. Almost half of the patients experienced a delay in admission, most commonly due to a lack of ICU bed availability. ICU mortality was 13.6% for patients admitted from the EC.DiscussionThe EC population referred to the ICU was young with a high burden of medical and trauma conditions. Decisions to accept patients to ICU are limited by available resources, and there was a need to apply ICU triage criteria. Delays in the transfer of ICU patients from the EC increase the workload and contribute to EC crowding.