Critical Care Center Research Articles

周産期の危機的病態にVA–ECMOを導入し良好な結果を得た3例(Three peripartum patients in critical condition successfully treated with extracorporeal circulation)

要旨周産期において急激に循環虚脱へ陥った産科救急3例に対して体外循環を導入し良好な結果を得た。3例はそれぞれ肺血栓塞栓症による呼吸循環不全，羊水塞栓症による肺水腫，周産期心筋症による心不全であった。うち1例は帝王切開後の子宮出血が止まらないなかでvenoarterial extracorporeal membrane oxygenation（VA–ECMO）を使用し，子宮摘出術を行った。もう1例はVA–ECMO導入後に緊急帝王切開を行った。3例とも危機的病態であったにもかかわらず神経学的異常はほとんどなく母児ともに良好な転帰を得ることができたが，うち2例の体外循環は標準的な妊産婦の蘇生治療ではないため今後の症例の集積が待たれる。急変した妊産婦の救命ならびに神経学的転帰の改善のためには，カンファレンスやシミュレーションによる母体救命システムについての意思統一が有効である。さらには，地域の産婦人科医，周産期センターと救命救急センターが日頃から産科救急に柔軟に協働し，必要に応じて循環虚脱や重症呼吸不全に対して迅速に体外循環を導入できる体制が重要である。

Infection control measures based on drug susceptibility to Acinetobacter baumannii.

In recent decades, Acinetobacter baumannii has been recognized as a nosocomial pathogen most prevalent in summer, with broad clinical manifestations and multidrug resistance posing a global threat.1, 2 We previously reported an outbreak of multidrug-resistant A. baumannii (MDR-AB) carrying oxacillinase(OXA)-51-like and ISAba1 genes.3 Therefore, we carried out screening tests in the critical care center (CCC) and intensified countermeasures against A. baumannii. Here we present the results of the drug susceptibility-based infection control measures. We included all patients in our CCC from January 2012 to December 2019 and screened a sputum or throat swab using selective medium for Acinetobacter spp. to determine the presence of A. baumannii and their drug susceptibility. Starting in January 2016, a new measure was introduced to isolate all cases in a private room for 72 h until screening results were confirmed. When private rooms were not open, CCC admission was restricted. In addition to standard precautions, patients with MDR-AB and extensively drug-resistant A. baumannii (XDR-AB) were managed by a dedicated team of physicians and nurses, and disposal of equipment following use or use of separate sets of mobile devices were implemented. Multidrug-resistant AB is defined as resistance to at least three categories of antimicrobials and XDR-AB is defined as MDR plus resistance to carbapenems.4 Data are presented as the mean and SEM of infected patients every 3 months, to observe the seasonal changes, and compared by Student's t-test. During active surveillance between January 2012 and December 2019, we identified 72 individuals with A. baumannii, including two ventilator-associated pneumonia and one bacteremia. Figure 1 shows that the number of patients with A. baumannii significantly decreased from 3.13 ± 0.50/3 months to 1.38 ± 0.41/3 months after the medical staff implemented systematic infection control measures based on the drug susceptibility in January 2016 (p = 0.01). In addition, the numbers of MDR-AB and XDR-AB patients significantly decreased from 1.94 ± 0.38/3 months to 0.38 ± 0.26/3 months (p < 0.002). We contained the outbreak by screening all patients admitted to the CCC and by focusing on MDR-AB and XDR-AB. Acinetobacter baumannii can persist in the environment of respiratory and medical equipment for several days,5 so the drug susceptibility-based isolation of the medical team and medical devices led to the end of the outbreak. However, the decrease in A. baumannii might be due not only to isolation measures based on drug susceptibility, but also years of education for health-care workers, environmental cleanup, including temporary CCC closure, and repeated audits of handwashing by the infection control team. Therefore, drug susceptibility-based infection control is one of the effective strategies because of limited medical resources, both financial and human. This work was supported by JSPS KAKENHI Grant Number JP15H04795. The authors declare no conflicts of interest. Approval of the research protocol: This study was approved by the institutional review board of the National Human Genome Research Institute and the Ethics Committee of the Faculty of Medicine, Juntendo University Urayasu Hospital (approval No. 30-004), and conducted according to the principles of the Declaration of Helsinki. Informed consent: Informed consent was obtained from guardians by opt-out in publicity documents. Registry and registration no. of the study/trial: N/A. Animal studies: N/A.

1160: COLLAPSE-RELATED TRAUMATIC INTRACRANIAL HEMORRHAGE AFTER OUT-OF-HOSPITAL CARDIAC ARREST

Introduction: Sudden collapse of out-of-hospital cardiac arrest (OHCA) patients due to internal cardiac arrest can be complicated by subsequent traumatic head injuries. Collapse-related traumatic intracranial hemorrhage (CRTIH) is especially important due to likely subsequent antiplatelet and anticoagulation therapy and the potential risk of exacerbation of hemorrhage and mortality. However, the prevalence and risk of CRTIH have not yet been elucidated. We hypothesized that CRTIH after OHCA is rarely observed but associated with unfavorable outcomes. Methods: We conducted a multicenter, retrospective observational study over a 13-year period (2007-2019) at five emergency and critical care centers. Inclusion criteria: adult OHCA patients with non-traumatic causes of arrest who were resuscitated and underwent head computed tomography. Exclusion criteria: stroke (ischemic/hemorrhagic) as cause of OHCA. The study’s primary outcome was to elucidate the prevalence of CRTIH. Baseline characteristics were compared between the CRTIH group and non-CRTIH group. Further, factors related to unfavorable patient neurological outcomes were examined using multivariable logistic regression analysis. Finally, the detailed clinical courses of CRTIH were described. Results: CRTIH following OHCA was observed in 8/427 (1.9%) patients. CRTIH was associated with collapse outside the home (CRTIH; 7/8 [87.5%] vs. non-CRTIH; 270 /419 [12.5%], p=0.027), external head surface injury (CRTIH; 4/8 [50.0%] vs. non-CRTIH; 18/419 [4.3%], p=0.008), and extracorporeal membrane oxygenation (CRIH; 3/8 [37.5%] vs. non-CRTIH; 44/419 [10.5%], p=0.047). CRTIH was not significantly associated with unfavorable outcome at 28 days (adjusted odds ratio 0.68; 95% confidence interval 0.10–4.70; p =0.697). Among eight patients with CRTIH, six had collapsed from orthostatic position, five were administered anticoagulants or antiplatelets after admission, two had hemorrhage exacerbation, one underwent neurosurgical decompression. Conclusions: CRTIH was rare among our patients with OHCA and was not significantly associated with unfavorable outcomes. However, cautious monitoring for exacerbation of hemorrhage in CRTIH patients with anticoagulant/antiplatelet/ECMO use after OHCA is needed.

Crisis Triage in the Era of COVID-19: Old Tools, New Approaches, and Unanswered Questions.

1 Division of Pulmonary, Allergy, Critical Care Medicine and Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 2 Emory Critical Care Center, Emory University, Atlanta, GA 3 Acute Care Surgery Division, Department of Surgery, Keck School of Medicine of USC, Los Angeles, CA 4 Critical Care Institute, Keck Hospital of USC, Los Angeles, CA 5 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA *See also p. 57. Dr. Cobb’s institution received funding from the Centers for Disease Control and Prevention Foundation; he received funding from Akido Labs, BauHealth, and GibLib. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Physician and Trainee Perceptions of Telecritical Care Practice and Education: Results of a Programmatic Survey.

Telecritical care (TCC) as a telehealth modality seeks to remedy contemporary shortfalls in staffing and experience at the bedside. Physician and physician trainee perceptions of TCC practice and education can help inform programmatic and curricular decisions. The perceptions of TCC and a formalized structured TCC rotation from faculty and trainees are unknown. To evaluate perceptions of TCC practice and education among participating physicians and trainees. Survey of physicians and trainees participating in the Emory Critical Care Center's TCC unit from 2017 to 2021 was conducted, after implementation of a structured TCC educational curriculum. Items were developed with a 5-point Likert scale. The overall response rate was 71% (43 of 61). Most respondents felt their knowledge was used appropriately and that their recommendations were well received at the bedside. The majority perceived that the TCC program improved continuity, quality, and safety of patient care. More than half of respondents would practice TCC in the future, and most would advocate for it. Most fellows were comfortable providing patient care remotely after their rotation. The majority of respondents felt TCC did not add to their level of burnout. This programmatic evaluation identified perceived improvements in patient care. Implementation of a TCC rotation does not seem to negatively impact the educational experience of trainees.

Aviptadil for COVID-19: A Case Study and Call to Action About the Challenges of Research During a Global Pandemic.

1 Emory Critical Care Center (ECCC), Atlanta, GA 2 Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 3 Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA *See also p. 1545. Dr. Auld has disclosed that she does not have any potential conflicts of interest.

Factors Influencing Emergency Department Nurses' Attitudes Toward Patients Who Attempted Suicide: A Mixed Methods Study.

Caring for patients who attempted suicide is essential to suicide prevention. The current mixed methods study clarified the factors influencing emergency department nurses' attitudes toward patients who attempted suicide. Questionnaires were distributed to 2,122 nurses at 73 critical care and medical center facilities in Japan; data of 419 participants were deemed valid and included in multiple regression analysis. Nurses' thoughts and emotions experienced when trying to empathize with patients, educational background, anxiety about caring for survivors of attempted suicide, severity of wounds inflicted during the suicide attempt, selfish behaviors by survivors, nurse-physician relationships, comparisons between survivors and other patients, and personal life experiences were identified as influencing factors. Training nurses to care for survivors of attempted suicide and fostering a climate in which nurses can easily collaborate with other specialists can help them understand such patients better. [Journal of Psychosocial Nursing and Mental Health Services, 61(5), 25-33.].

Racial Disparities in Donor Human Milk Feedings: A Study Using Electronic Medical Records.

The aim of this study was to evaluate differences in the use of pasteurized donor human milk (PDHM) by maternal race-ethnicity during postpartum hospitalization using electronic medical records (EMRs). A retrospective cohort study of all live-born infants at our academic research institution from July 1, 2014, to June 30, 2016, was conducted. EMR data were used to determine whether each infant received mother's own milk (MOM), PDHM, or formula. These data were stratified based on whether the infant received treatment in the Neonatal Critical Care Center. Generalized estimating equation models were used to calculate the odds of receiving PDHM by maternal race-ethnicity, adjusting for gestational age, birth weight, insurance, preferred language, nulliparity, and mode of delivery. Infant feeding data were available for 7097 infants, of whom 49% were fed only MOM during their postpartum hospitalization. Among the 15.9% of infants admitted to neonatal critical care, infants of non-Hispanic Black (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.31-0.72), Hispanic (OR 0.65, 95% CI 0.36-1019), and Other (OR 0.63, 95% CI 0.32-1.26) mothers had lower rates of PDHM feedings than infants of non-Hispanic White mothers in the adjusted models. Among well infants, the use of PDHM was lower among non-Hispanic Black and Hispanic mothers (OR 0.25, 95% CI 0.18-0.36, and OR 0.38, 95% CI 0.26-0.56) compared with non-Hispanic White mothers. Inequities in exclusive human milk feeding and use of PDHM by maternal race-ethnicity were identified. Antiracist interventions are needed to promote equitable access to skilled lactation support and counseling for PDHM use.

Enhanced disinfection with hybrid hydrogen peroxide fogging in a critical care setting

BackgroundEnvironmental contamination contributes to hospital associated infections, particularly those caused by multi-drug resistant organisms (MDRO). This study investigated bioburden presence on surfaces in a critical care center’s patient rooms following typical environmental services (EVS) practices and following intervention with hybrid hydrogen peroxide™ (HHP™) fogging.MethodsUpon patient discharge, following standard cleaning or cleaning with ultraviolet (UV) light use, patient rooms were sampled by swabbing for adenosine triphosphate (ATP) and aerobic colony counts (ACC) from five preset locations. Rooms were then fogged via HHP technology using chemical indicators and Geobacillus stearothermophilus biological indicators for sporicidal validation monitoring. Following fogging, rooms were sampled again, and results were compared.ResultsA 98% reduction in ACC was observed after fogging as compared to post EVS practices both with and without UV light use. No statistical difference was seen when comparing cleaning to cleaning with UV light use. Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa were identified following EVS practices and not detected following HHP fogging. ATP samples were reduced 88% by fogging application. Chemical and biological indicators confirmed correct application of HHP fogging, as seen through its achievement of a 6-log reduction of bacterial spores.ConclusionHHP fogging is a thorough and efficacious technology which, when applied to critical care patient rooms, significantly reduces bioburden on surfaces, indicating potential benefits for implementation as part of infection prevention measures.

Cost-effectiveness of an Emergency Department–Based Intensive Care Unit

Value in health care is quality per unit cost (V = Q/C), and an emergency department-based intensive care unit (ED-ICU) model has been associated with improved quality. To assess the value of this care delivery model, it is essential to determine the incremental direct cost of care. To determine the association of an ED-ICU with inflation-adjusted change in mean direct cost of care, net revenue, and direct margin per ED patient encounter. This retrospective economic analysis evaluated the cost of care delivery to patients in the ED before and after deployment of the Joyce and Don Massey Family Foundation Emergency Critical Care Center, an ED-ICU, on February 16, 2015, at a large academic medical center in the US with approximately 75 000 adult ED visits per year. The pre-ED-ICU cohort was defined as all documented ED visits by patients 18 years or older with a complete financial record from September 8, 2012, through June 30, 2014 (660 days); the post-ED-ICU cohort, all visits from July 1, 2015, through April 21, 2017 (660 days). Fiscal year 2015 was excluded from analysis to phase in the new care model. Statistical analysis was performed March 1 through December 30, 2021. Implementation of an ED-ICU. Inflation-adjusted direct cost of care, net revenue, and direct margin per patient encounter in the ED. A total of 234 884 ED visits during the study period were analyzed, with 115 052 patients (54.7% women) in the pre-ED-ICU cohort and 119 832 patients (54.5% women) in the post-ED-ICU cohort. The post-ED-ICU cohort was older (mean [SD] age, 49.1 [19.9] vs 47.8 [19.6] years; P < .001), required more intensive respiratory support (2.2% vs 1.1%; P < .001) and more vasopressor use (0.5% vs 0.2%; P < .001), and had a higher overall case mix index (mean [SD], 1.7 [2.0] vs 1.5 [1.7]; P < .001). Implementation of the ED-ICU was associated with similar inflation-adjusted total direct cost per ED encounter (pre-ED-ICU, mean [SD], $4875 [$15 175]; post-ED-ICU, $4877 [$17 400]; P = .98). Inflation-adjusted net revenue per encounter increased by 7.0% (95% CI, 3.4%-10.6%; P < .001), and inflation-adjusted direct margin per encounter increased by 46.6% (95% CI, 32.1%-61.2%; P < .001). Implementation of an ED-ICU was associated with no significant change in inflation-adjusted total direct cost per ED encounter. Holding delivery costs constant while improving quality demonstrates improved value via the ED-ICU model of care.

Semi-quantitative evaluation of chest computed tomography for coronavirus disease 2019 in a critical care unit: A case-control study.

The spread of abnormal opacity on chest computed tomography (CT) has been reported as a predictor of coronavirus disease 2019 (COVID-19) severity; however, the relationship between CT findings and prognosis in patients with severe COVID-19 remains unclear. The objective of this study was to evaluate the extent of abnormal opacity on chest CT and its association with prognosis in patients with COVID-19 in a critical care medical center, using a simple semi-quantitative method. This single-center case-control study included patients diagnosed with severe COVID-19 pneumonia who were admitted to a critical care center. The diagnosis of COVID-19 was based on positive results of a reverse transcription polymerase chain reaction test. All patients underwent non-contrast whole-body CT upon admission. Six representative axial chest CT images were selected for each patient to evaluate the extent of lung lesions. The percentage of the area involved in the representative CT images was visually assessed by 2 radiologists and scored on 4-point scale to obtain the bedside CT score, which was compared between patients who survived and those who died using the Mann–Whitney U test. A total of 63 patients were included in this study: 51 survived and 12 died after intensive treatment. The inter-rater reliability of bedside scores between the 2 radiologists was acceptable. The median bedside CT score of the survival group was 12.5 and that of the mortality group was 16.5; the difference between the 2 groups was statistically significant. The degree of opacity can be easily scored using representative CT images in patients with severe COVID-19 pneumonia, without sophisticated software. A greater extent of abnormal opacity is associated with poorer prognosis. Predicting the prognosis of patients with severe COVID-19 could facilitate prompt and appropriate treatment.

Effectiveness of Nursing Strategies on Cardiac parameters among patients with hypotension admitted in Dhanvantri Critical Care Centre, Erode

Background: Hypotension refers to an abnormally low blood pressure (BP) below 80/60. The role of nursing in treating the patients with hypotension is having a lot of importance. Objectives: To assess the Effectiveness of Nursing Strategies on Cardiac parameters among patients with hypotension admitted in Dhanvantri Critical Care Centre, Erode. Design: Quasi-experimental design, where Pre and Post test Non equivalent Group design, Setting: Dhanvantri Critical Care Centre, Erode. Methods: Out of 30 patients, 20 patients were selected as experimental group and 10 patients were selected as control group by using purposive sampling technique. Level of cardiac function was measured by cardiac parameters observational scale before and after the procedure. Results: Scores in cardiac function shows, posttest 80% of patients had moderate level of cardiac function in control group whereas on experimental group 95% of patients had normal level of cardiac function. The patient’s level of cardiac parameters improved from the mean value of 12.7±1.59 to 12.5±2.18 in control group and 11.8± 2.07 to 19.2±2.66 in experimental group respectively. Paired ‘t’ test score was 3.462 and 27.49 in control and experimental group. Unpaired ‘t’ test score was 5.44 which is significantly effective. Conclusion: The findings of the study reveal that Fluid therapy and passive leg raising is more effective and it improves the level of cardiac function in patients with hypotension.

Development of a web system for the record of Clinical History in patients of the State Center for Critical Care in Salamanca Gto.

Software development is a common practice carried out for different institutions, both public and private. The purpose of these developments is to improve processes, streamline tasks and keep a record and control of the information so that it can later be used for decision making. The development of the Clinical History software for the State Critical Care Center in Salamanca Guanajuato (CECCS) by the Academy of Network and Telecommunications Engineering of the Polytechnic University of Juventino Rosas, meets the requirements requested by the CECCS. This system was requested to replace manual processes that are carried out by medical and nursing personnel; these processes will be replaced by a digital registry, where the information will be permanently recorded in a database. This system starts with the registration of the patient who enters the CECCS for hospitalization, the system will assign a file number for its control. By means of this file number, the nursing staff will generate the records of both diagnosis and medications administered in the three shifts (morning, afternoon and night), these records will be carried out by means of the sheet concept (one sheet will be recorded per day of the patient's hospitalization) where each sheet will contain six pages which contain: physiological parameters, hydric response, respiratory parameters, clinical parameters, neurological assessment, device infection risk assessment, pressure ulcer assessment, burns assessment, pharmacotherapies, intravenous therapy, diagnosis and nursing standards. This system also has a role control per user, where, depending on the user's role, are the options that can be executed within the system. There is a user authentication at the beginning of the system, so that only authorized personnel can use and register the information.

Healthcare Transition in Outpatient Clinics

Many cases of healthcare transition were referred to the Department of Neurology in our local core hospital with an emergency and critical care center, owing to the relocation of a nearby children's medical center. Most patients presented epilepsy with difficulty in controlling seizures or were children with severe mental and physical disabilities requiring medical care. During the transition, multidisciplinary collaboration centered on the medical consultation office was conducted. After the transition, many patients were transported to emergency rooms for seizures, pneumonia, and other infectious diseases. Education, advanced care planning, and regional collaboration were some of the issues in the process.

Impact of Rational Emotive Behaviour Therapy (REBT) on Suicidal ideation among attempted suicide patients in Dhanvantri Critical Care Centre at Erode

Context: Suicide attempts cause serious emotional, physical, and economic impacts. Suicidal ideations (SI), often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes and preoccupations with death and suicide. Rational emotive behavior therapy (REBT) is a type of therapy that helps to identify irrational beliefs and negative thought patterns that may lead to emotional or behavioural issues. Methods: The research design selected for the present study was pre experimental design, where one group pretest posttest design was adopted. The present study was conducted in Dhanvantri Critical Care Centre at Erode. The total sample size was 50 suicide patients. The investigator selected the subjects by adopting purposive sampling technique. The background variables and clinical variables were assessed. The level of suicidal ideation was assessed by using suicidal ideation questionnaire. REBT sessions were conducted for the period of 4 weeks. Face to face sessions and subsequent follow up sessions were conducted. Posttest was conducted by using the same assessment tool. Results: The study findings revealed that administration of REBT were highly significant in the reduction of suicidal ideation among attempted suicide patients.

A continuous intravenous insulin infusion protocol to manage high-dose methylprednisolone-induced hyperglycemia in patients with severe COVID-19

BackgroundMany patients with severe COVID-19 have impaired glucose tolerance, and steroid therapy is a standard treatment. Thus, good glycemic control is important and correlates with better patient outcomes. We began using a continuous intravenous insulin infusion protocol for glycemic control whose infusion rate changes based on the currently measured value and previous value. This study aimed to evaluate this protocol for COVID-19 patients requiring mechanical ventilation.MethodsThis single-center, retrospective, case control study was conducted on all adult patients who required mechanical ventilation for severe COVID-19 pneumonia admitted to our critical care center from April 1, 2020 through June 20, 2021. Blood glucose levels were measured in all patients every 4 h after admission. We started using the insulin infusion protocol from August 1, 2020. Patients before starting the protocol comprised the non-protocol group and those after starting the protocol comprised the protocol group. Blood glucose levels and hypo- or hyperglycemia events were compared between groups. We also surveyed ICU nurses about their experience using the protocol.ResultsDuring the study period, 173 patients with COVID-19 were admitted. After 15 patients were excluded for several reasons, the study included 158 patients: non-protocol group (n = 14) and protocol group (n = 144). In the initial phase (days 1–2), blood glucose levels of the protocol group were higher compared with the non-protocol group, and as the number of measurements increased, blood glucose levels were gradually brought under control within the target range in the protocol group. Almost no hypoglycemic events (blood glucose < 80 mg/dL) were detected in either group. The rate of hyperglycemia (blood glucose > 300 mg/dL) was about 5–10% in the initial phase in the protocol group and about 10–15% in the early phase (days 3–4) in the non-protocol group. The questionnaire survey revealed that 80% of ICU nurses responded favorably.ConclusionsThis insulin protocol gradually brought the blood glucose level within target levels in severe COVID-19 patients treated with high-dose steroid. Some hyperglycemia events were detected despite patients being under the protocol in the initial phase, and thus, minor modifications of the protocol might be required in the initial phase.

Not all is lost: Dynamic functional recovery in older adults following emergency general surgery.

Division of Traumatology, Surgical Critical Care and Emergency Surgery Penn Presbyterian Medical Center Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania The authors declare no conflicts of interest.

Models of Care in Geriatric Intensive Care-A Scoping Review on the Optimal Structure of Care for Critically Ill Older Adults Admitted in an ICU.

OBJECTIVE:A growing proportion of critically ill patients admitted in ICUs are older adults. The need for improving care provided to older adults in critical care settings to optimize functional status and quality of life for survivors is acknowledged, but the optimal model of care remains unknown. We aimed to identify and describe reported models of care.DATA SOURCES:We conducted a scoping review on critically ill older adults hospitalized in the ICU. Medline (PubMed), Embase (OvidSP), Cumulative Index to Nursing and Allied Health Literature (Ebsco), and Web of Science (Clarivate) were searched from inception to May 5, 2020.STUDY SELECTION:We included original articles, published abstracts, review articles, editorials, and commentaries describing or discussing the implementation of geriatric-based models of care in critical care, step-down units, and trauma centers. The organization of care had to be described. Articles only discussing geriatric syndromes and specific interventions were not included.DATA EXTRACTION:Full texts of included studies were obtained. We collected publication and study characteristics, structures of care, human resources used, interventions done or proposed, results, and measured outcomes. Data abstraction was done by two investigators and reconciled, and disagreements were resolved by discussion.DATA SYNTHESIS:Our search identified 3,765 articles, and we found 19 reporting on the implementation of geriatric-based models of care in the setting of critical care. Four different models of care were identified: dedicated geriatric beds, geriatric assessment by a geriatrician, geriatric assessment without geriatrician, and a fourth model called “other approaches” including geriatric checklists, bundles of care, and incremental educational strategies. We were unable to assess the superiority of any model due to limited data.CONCLUSIONS:Multiple models have been reported in the literature with varying degrees of resource and labor intensity. More data are required on the impact of these models, their feasibility, and cost-effectiveness.

Effects of early rehabilitation in sepsis patients by a specialized physical therapist in an emergency center on the return to activities of daily living independence: A retrospective cohort study.

BackgroundEarly rehabilitation allows patients to better perform the activities of daily living after hospital discharge. A specialized physical therapist has been assigned as part of the early rehabilitation, but the effectiveness of the program remains unclear. We investigated how early rehabilitation provided by a specialized physical therapist affects ADL in patients with sepsis.MethodsThis was a retrospective cohort study. This study’s subjects were sepsis patients who entered the advanced emergency critical care center of Shinshu University Hospital between April 2014 and March 2020. Electronic medical records were reviewed to obtain information on demographic characteristics, severity score, primary source of infection, therapeutic medication, the number of days after hospital admittance until rehabilitation begins, length of hospital stay, discharge to home, and an assessment of daily living activities for each patient. The patients were divided into two groups based on whether they were treated before or after a specialized physical therapist had been hired by the advanced emergency critical care center.ResultsAssigning a physical therapist to a patient significantly shortened the number of days until rehabilitation began. In a multivariable model, the strongest predictors of return to independent living after hospital discharge were (1) assigning a specialized physical therapist (odds ratio = 2.40; 95% confidence interval = 1.09–5.79; P = 0.050) and (2) the number of days until rehabilitation started (odds ratio = 0.24; 95% confidence interval = 0.08–0.76; P = 0.014).ConclusionsAssigning a specialized physical therapist to sepsis patients at an advanced emergency critical care center significantly shortened the number of days until a patient can begin rehabilitation after hospital admittance and improved activities of daily living after hospital discharge.Trial registrationTrial registration [University Hospital Medical Information Network Clinical Trials Registry, number UMIN000040570 (2020/5/28).]

Neutralisation Hierarchy of SARS-CoV-2 Variants of Concern Using Standardised, Quantitative Neutralisation Assays Reveals a Correlation With Disease Severity; Towards Deciphering Protective Antibody Thresholds.

The rise of SARS-CoV-2 variants has made the pursuit to define correlates of protection more troublesome, despite the availability of the World Health Organisation (WHO) International Standard for anti-SARS-CoV-2 Immunoglobulin sera, a key reagent used to standardise laboratory findings into an international unitage. Using pseudotyped virus, we examine the capacity of convalescent sera, from a well-defined cohort of healthcare workers (HCW) and Patients infected during the first wave from a national critical care centre in the UK to neutralise B.1.1.298, variants of interest (VOI) B.1.617.1 (Kappa), and four VOCs, B.1.1.7 (Alpha), B.1.351 (Beta), P.1 (Gamma) and B.1.617.2 (Delta), including the B.1.617.2 K417N, informally known as Delta Plus. We utilised the WHO International Standard for anti-SARS-CoV-2 Immunoglobulin to report neutralisation antibody levels in International Units per mL. Our data demonstrate a significant reduction in the ability of first wave convalescent sera to neutralise the VOCs. Patients and HCWs with more severe COVID-19 were found to have higher antibody titres and to neutralise the VOCs more effectively than individuals with milder symptoms. Using an estimated threshold for 50% protection, 54 IU/mL, we found most asymptomatic and mild cases did not produce titres above this threshold.