ICU Resources Research Articles

Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death.

To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality. Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%. Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003). Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.

Emergently planned exclusive hub-and-spoke system in the epicenter of the first wave of COVID-19 pandemic in Italy: the experience of the largest COVID-19-free ICU hub for time-dependent diseases.

Lombardy was the epicenter in Italy of the first wave of COVID-19 pandemic. To face the contagion growth, from March 8 to May 8, 2020, a regional law redesigned the hub-and-spoke system for time-dependent diseases to better allocate resources for COVID-19 patients. We report the reorganization of the major hospital in Lombardy during COVID-19 pandemic, including the rearrangement of its ICU beds to face COVID-19 pandemic and fulfill its role as extended hub for time-dependent diseases while preserving transplant activity. To highlight the impact of the emergently planned hub-and-spoke system, all patients admitted to a COVID-19-free ICU hub for trauma, neurosurgical emergencies and stroke during the two-month period were retrospectively collected and compared to 2019 cohort. Regional data on organ procurement was retrieved. Observed-to-expected (OE) in-ICU mortality ratios were computed to test the impact of the pandemic on patients affected by time-dependent diseases. Dynamic changes in ICU resource allocation occurred according to local COVID-19 epidemiology/trends of patients referred for time-dependent diseases. The absolute increase of admissions for trauma, neurosurgical emergencies and stroke was roughly two-fold. Patients referred to the hub were older and characterized by more severe conditions. An increase in crude mortality was observed, though OE ratios for in-ICU mortality were not statistically different when comparing 2020 vs. 2019. An increase in local organ procurement was observed, limiting the debacle of regional transplant activity. We described the effects of a regional emergently planned hub-and-spoke system for time-dependent diseases settled in the epicenter of COVID-19 pandemic in Italy.

Prioritising \u2018already-scarce\u2019 intensive care unit resources in the midst of COVID-19: a call for regional triage committees in South Africa

BackgroundThe worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context.DiscussionBeyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation.ConclusionWe propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.

Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis.

Rationale: Initial reports of case fatality rates (CFRs) among adults with coronavirus disease (COVID-19) receiving invasive mechanical ventilation (IMV) are highly variable.Objectives: To examine the CFR of patients with COVID-19 receiving IMV.Methods: Two authors independently searched PubMed, Embase, medRxiv, bioRxiv, the COVID-19 living systematic review, and national registry databases. The primary outcome was the “reported CFR” for patients with confirmed COVID-19 requiring IMV. “Definitive hospital CFR” for patients with outcomes at hospital discharge was also investigated. Finally, CFR was analyzed by patient age, geographic region, and study quality on the basis of the Newcastle-Ottawa Scale.Measurements and Results: Sixty-nine studies were included, describing 57,420 adult patients with COVID-19 who received IMV. Overall reported CFR was estimated as 45% (95% confidence interval [CI], 39–52%). Fifty-four of 69 studies stated whether hospital outcomes were available but provided a definitive hospital outcome on only 13,120 (22.8%) of the total IMV patient population. Among studies in which age-stratified CFR was available, pooled CFR estimates ranged from 47.9% (95% CI, 46.4–49.4%) in younger patients (age ≤40 yr) to 84.4% (95% CI, 83.3–85.4%) in older patients (age >80 yr). CFR was also higher in early COVID-19 epicenters. Overall heterogeneity is high (I2 >90%), with nonsignificant Egger’s regression test suggesting no publication bias.Conclusions: Almost half of patients with COVID-19 receiving IMV died based on the reported CFR, but variable CFR reporting methods resulted in a wide range of CFRs between studies. The reported CFR was higher in older patients and in early pandemic epicenters, which may be influenced by limited ICU resources. Reporting of definitive outcomes on all patients would facilitate comparisons between studies.Systematic review registered with PROSPERO (CRD42020186997).

Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill.

With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them. A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS). The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease. Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.

It is not just about equipment and beds: Critical care nursing meeting the challenge of the second COVID-19 wave in Italy.

It is not just about equipment and beds: Critical care nursing meeting the challenge of the second COVID-19 wave in Italy.

A novel ethical approach to moral distress during COVID 19 in New York

The initial surge of COVID19 patients in New York, created a surge of unprecedented numbers in the largest integrated hospital system of the New York City and surrounding Long Island region. Due to innovation and clinician ingenuity ventilator allocation was going to have an easier solution than alleviating the moral distress of overworked and understaffed clinicians. Through the innovative work of clinicians, leadership and the leadership of Governor Cuomo and hospital executives, the need for triaging ventilators did not become a reality. Yet the need for ethicists to support and aid clinicians in the discernment and need for escalation for scarce ICU resources and personnel was key. The transition from an allocation strategy of ventilators organically occurred as rapidly as the surge of COVID19 as it became clear that addressing clinician distress was imperative to maintain the level of human capital. An allocation strategy was envisioned that would assess the urgency of need for intensive care resources utilizing established decision aid calculators. In a mixed method quantitative and qualitative review, this article utilizes descriptive data to illustrate the lessons learned from utilizing ethics consultants to review pandemic decision making and alleviate clinician moral distress.

Abstract 16759: In-Hospital Outcomes of Coronary Artery Bypass Grafting Candidates Undergoing Percutaneous Coronary Intervention During the Intensive Care Unit Restricted Covid-19 Pandemic: The Multi-Centre Prospective UK-REVASC Registry

Introduction: The COVID-19 pandemic has restricted availability of ICU resources. Symptomatic patients with coronary artery disease (CAD) normally considered surgical candidates have therefore required alternative revascularization with percutaneous coronary intervention (PCI). The UK-REVASC registry describes the demographics and in-hospital clinical outcomes of this novel patient cohort. Methods: From 1 st March to 31 st May 2020, anonymised data of 171 patients from 38 UK centres were enrolled in a prospective, observational registry. All were on surgical waiting lists or considered for surgery. Results: The demographics, procedural characteristics and outcomes are shown in Tables 1-3. A comparison with routine PCI British Cardiovascular Intervention Society (BCIS) data and UK isolated coronary bypass surgical data are listed, where available and appropriate. The median age was 68 (IQR 60-76) years. There was significantly more previous MI, PCI and CABG in the routine PCI database than in ReVasc Registry patients, perhaps suggesting a more acute presentation with accelerated symptoms in the test group. These were however complex patients with a mean SYNTAX Score (SS) of 27.8 (range 9-65) and &gt;20x the number of LMS plus multi-vessel disease compared to the routine PCI group, which is reflected in a high use of adjunctive imaging. Radial access was very high at 94.1%. PCI success was 97.0%. Complete revascularization was achieved in 52% with the mean residual SS 1.42 (0-20) in these. There were 2 deaths, however the mortality rate was comparable with published surgical data. Furthermore, a 50% reduction in in-patient stay was observed. Conclusion: In this multi-centre UK registry, in-hospital outcomes following PCI for patients with complex coronary disease, who would typically be treated with CABG, compared well with the surgical data. This suggests that the role of PCI could be extended. Future longer term follow-up however is required and planned.

Risk factors for the critical illness in SARS-CoV-2 infection: a multicenter retrospective cohort study

BackgroundPrior studies reported that 5 ~ 32% COVID-19 patients were critically ill, a situation that poses great challenge for the management of the patients and ICU resources. We aim to identify independent risk factors to serve as prediction markers for critical illness of SARS-CoV-2 infection.MethodsFifty-two critical and 200 non-critical SARS-CoV-2 nucleic acid positive patients hospitalized in 15 hospitals outside Wuhan from January 19 to March 6, 2020 were enrolled in this study. Multivariable logistic regression and LASSO logistic regression were performed to identify independent risk factors for critical illness.ResultsAge older than 60 years, dyspnea, respiratory rate > 24 breaths per min, leukocytosis > 9.5 × 109/L, neutrophilia > 6.3 × 109/L, lymphopenia < 1.1 × 109/L, neutrophil-to-lymphocyte ratio > 3.53, fibrinogen > 4 g/L, d-dimer > 0.55 μg/mL, blood urea nitrogen > 7.1 mM, elevated aspartate transaminase, elevated alanine aminotransferase, total bilirubin > 21 μM, and Sequential Organ Failure Assessment (SOFA) score ≥ 2 were identified as risk factors for critical illness. LASSO logistic regression identified the best combination of risk factors as SOFA score, age, dyspnea, and leukocytosis. The Area Under the Receiver-Operator Curve values for the risk factors in predicting critical illness were 0.921 for SOFA score, 0.776 for age, 0.764 for dyspnea, 0.658 for leukocytosis, and 0.960 for the combination of the four risk factors.ConclusionsOur findings advocate the use of risk factors SOFA score ≥ 2, age > 60, dyspnea and leukocytosis > 9.5 × 109/L on admission, alone or in combination, to determine the optimal management of the patients and health care resources.

Management of acute and chronic aortic disease during the COVID-19 pandemic-Results from a web-based ad hoc platform.

BackgroundTo share the results of a web‐based expert panel discussion focusing on the management of acute and chronic aortic disease during the coronavirus (COVID‐19) pandemic.MethodsA web‐based expert panel discussion on April 18, 2020, where eight experts were invited to share their experience with COVID‐19 disease touching several aspects of aortic medicine. After each talk, specific questions were asked by the online audience, and results were immediately evaluated and shared with faculty and participants.ResultsAs of April 18, 73.3% answered that more than 200 patients have been treated at their respective settings. Sixty‐four percent were reported that their hospital was well prepared for the pandemic. In 57.7%, the percentage of infected healthcare professionals was below 5% whereas 19.2% reported the percentage to be between 10% and 20%. Sixty‐seven percent reported the application of extracorporeal membrane oxygenation in less than 2% of COVID‐19 patients whereas 11.8% reported application in 5%–10% of COVID‐19 patients. Thirty percent of participants reported the occurrence of pulmonary embolism in COVID‐19 patients. Three percent reported to have seen aortic ruptures in primarily elective patients having been postponed because of the anticipated need to provide sufficient ICU capacity because of the pandemic. Nearly 70% reported a decrease in acute aortic syndrome referrals since the start of the pandemic.ConclusionThe current COVID‐19 pandemic has—besides the stoppage of elective referrals—also led to a decrease of referrals of acute aortic syndromes in many settings. The reluctance of patients seeking medical help seems to be a major driver. The number of patients, who have been postponed due to the provisioning of ICU resources but having experienced aortic rupture in the waiting period, is still low. Further, studies are needed to learn more about the influence that the COVID‐19 pandemic has on the treatment of patients with acute and chronic aortic disease.

RIB fracture triage pathway decreases ICU utilization, pulmonary complications and hospital length of stay

IntroductionRib fractures are one of the most frequent causes of morbidity following blunt injury to the chest. Many of these patients require ICU care and often develop pulmonary complications. Prior studies have attempted to identify changes in predicted lung volumes or utilized the number of rib fractures to guide clinical decisions. A rib fracture triage pathway was developed to identify which patients will benefit from ICU level of care and shorten hospital length of stay for patients that do not require ICU care. MethodsThe triage pathway utilized patient's age, number of rib fractures, significant cardiopulmonary co-morbidities, and incentive spirometry volumes to determine admission disposition. The triage pathway was implemented on November 2016. All patients with rib fractures from November 2015 to 2017 were identified in the trauma registry. Data was collected on patients age, gender, Glasgow Coma Scale on arrival (GCS), injury severity score (ISS), number of rib fractures, incentive spirometry volumes, days in intensive care (ICU), ventilator days, length of stay (LOS), complications, and mortality. Patients with severe TBI, those arriving intubated, or died within 48 h were excluded. The patients remaining were 278 patients in the pre triage pathway group and 370 in the post triage pathway. ResultsThere was no difference in age, gender, GCS, ISS, predicted incentive spirometry or number of rib fractures. The post treatment patients required significantly lower ICU admissions (64% vs 75%, p = 0.003), significantly lower pulmonary complication (5.1% vs 10.4%, p = 0.01), and significantly shorter hospital length of stay (6.8 d vs 7.5, p = 0.001) with no difference in mortality (1.6% vs 2.5%, p = 0.42) or readmission (0.3% vs. 0.7%, p = 0.4). Patient post triage protocol were also more likely to be discharge home (81% vs 70%, p = 0.0009) with less patients going to a skilled nursing facility (13% vs 21%, p = 0.01). ConclusionsDeveloping a rib fracture treatment and triage pathway can decrease ICU and hospital resource utilization and decrease pulmonary complications without increase in readmissions or mortality. Patients are more likely to be discharge home over a skilled nursing facility further decreasing health care cost. Level of Evidence IV Retrospective Study, Prognostic

Characteristics and Outcomes of 4,942 Critically Ill Adult Patients with COVID-19 in Brazil

Background: The spread of COVID-19 increased the stress of health systems globally, obligating adjustments to improve the management of severe cases. What are the impacts of preparedness measures on the outcomes of the COVID-19 critically ill patients? Our study aimed to analyze the clinical characteristics, resource use, and risk factors associated with 30-day in-hospital mortality of critically ill adult patients with COVID-19 requiring ICU admission in a network of Brazilian hospitals.Methods: A multicenter cohort of COVID-19-confirmed patients requiring ICU admission at 42 Brazilian hospitals between February 27th and June 27th, 2020. The primary outcome was 30-day in-hospital mortality. We evaluated the association of clinical characteristics, ICU resource use, and risk factors using a random-effects multivariable cox regression model, in which the hospital was the random intercept. Secondary outcomes were the length-of-stay, ICU, and in-hospital mortality, and the use of mechanical ventilation during hospitalization.Findings: From 4,942 patients, 713 (14·4%) died 30 days after the ICU admission. The median age was 56 (IQR: [43,72]) years, 38% of patients were over 60 years-old, and 41% were women. Being older than 70 years (70-79, Hazard Ratio [95%CI]: 1·95[1·3-2·93]; ≥ 80, 3·96[2·66-5·89]), frail (MFI≥3, 1·65 [1·26-2·15]) and requiring, early or late, invasive Mechanical Ventilation (48h, 3·26 [2·46-4·32]) were independently associated with 30-day mortality. In 1,400 ventilated patients, 30-day mortality was 44·4% (622/1,400), the median duration of mechanical ventilation was ten days (IQR [6,16]), and ICU length of stay was 17 days (IQR [10,26]). Those who died within 30 days were more often older than 80 years (≥80: 37% vs. 14%) and previously frail (35% vs. 19%) compared to the survivors.Interpretation: In this large cohort, critically ill COVID-19 patients showed reasonable survival rates, including those requiring mechanical ventilation. Factors associated with worse outcome were age, frailty, and early need for invasive ventilation. Adequate preparedness, early hospitalization, and no shortage of critical care resources were probably key to achieve such results.Funding: The National Council for Scientific and Technological Development (CNPq); the Coordination for the Improvement of Higher Education Personnel (CAPES); the Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ); the Pontifical Catholic University of Rio de Janeiro and the D’Or Institute for Research and Education.Declaration of Interests: Dr. Soares and Dr. Salluh are founders and equity shareholders of Epimed Solutions®, which commercializes the Epimed Monitor System®, a cloud-based software for ICU management and benchmarking. The other authors declare that they have no conflict of interest.Ethics Approval Statement: Local Ethics Committee and the Brazilian National Ethics Committee (CAAE: 17079119.7.0000.5249) approved the study without the need for informed consent.

SUCCESSFUL USE OF HIGH FLOW NASAL CANNULA OUTSIDE OF THE CRITICAL CARE AREAS

SESSION TITLE: Respiratory Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: We continued to monitor and adjust our High Flow Nasal Cannula (HFNC) use in all areas. Our previous success of HFNC use outside of the critical care areas on our medical floors resulted in decreased ICU days and decreased noninvasive positive pressure ventilation (NIPPV) use. This study continues to evaluate the success of our HFNC use, including where to care for the patient, as well as whether we continue to use HFNC instead of NIPPV. Prior to our initiation of HFNC use on the medical floors, all patients on HFNC would have gone to the ICU on NIPPV. METHODS: We evaluated all patients on HFNC from 1/1/2016 to 12/31/2019. We looked at where HFNC was initiated, whether it was used on the medical floors or whether an ICU admission was needed. If an ICU transfer occurred, we then reviewed each case to determine if that patient required an escalation to NIPPV once in ICU. We then looked at the number of HFNC and NIPPV treatments from 1/1/2011 to 12/31/2019. RESULTS: From 2016-19 there were 1,517 patients admitted through the Emergency Department that were placed on HFNC. 564 patients were admitted directly to the medical floor on HFNC. 70 of these patients required a transfer to the ICU, where only 26 required NIPPV (26/564, 4.6%). 1,023 patients were admitted to the ICU and 568 were managed without NIPPV (56%). 188 patients were discharged to the floor from the ICU on HFNC, with none requiring rescue NIPPV. 129 HFNC ICU patients required NIPPV. 188 patients initially on NIPPV were transitioned to HFNC. 138 patients were on both during the day of admission to the ICU, not clear which was used first. HFNC patients treated on the medical floors were managed successfully without NIPPV 95.6% of the time. 494 ICU admissions were avoided, and many ICU days were decreased using HFNC. Over the 9-year period, there was a large increase in treatments with a shrinking percentage of NIPPV use. The average days on NIPPV was 1.65 and on HFNC was 2.96, many of these days on the floors. The average direct cost for patients treated with NIPPV, without HFNC, was $19,475. The average direct cost for HFNC, and no NIPPV was $10,194. CONCLUSIONS: Patients requiring HFNC can be safely managed outside of the critical care areas. Overall hospital costs were reduced. CLINICAL IMPLICATIONS: Managing HFNC outside of the critical care areas can free up ICU resources and decrease NIPPV use. Decreased NIPPV use allows for increased available therapist time, as NIPPV is time and labor-intensive for RTs. DISCLOSURES: Consultant relationship with Monaghan Medical Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Travel Consultant relationship with Vapotherm Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Travel Consultant relationship with Fisher & Paycal Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Grant/Research Support Consultant relationship with Fisher & Paykel Please note: $1001 - $5000 Added 03/03/2020 by Wendy Fascia, source=Web Response, value=Travel Consultant relationship with Fisher & Paykel Please note: $1001 - $5000 Added 03/03/2020 by Wendy Fascia, source=Web Response, value=Travel Removed 03/03/2020 by Wendy Fascia, source=Web Response Speaker/Speaker's Bureau relationship with Fisher Paykel Please note: $1001 - $5000 Added 03/03/2020 by Jennifer Pedley, source=Web Response, value=Travel

Impact on cardiac surgery volume of a comprehensive partnership with Integrated Health Solutions.

The New Brunswick Heart Centre (NBHC) entered a contractual partnership with Integrated Health Solutions (IHS) to help address increasing wait times in the province of New Brunswick. Team leaders were identified from each of the target areas, including surgeons, anesthesiologists, nurses (operating room, intensive care unit [ICU] and postoperative ward), access coordinators and administrators. The methodology used was based on Lean principles and involved exercises by stakeholders aimed at identifying opportunities for improvement. A weekly dashboard was created to monitor and facilitate improvement efforts. No additional hospital beds or operating room theatres were added during the study period. After 2 years, the annual number of cardiac surgical interventions increased from 788 to 873, representing a 10.8% increase in capacity. The best median wait time for patients decreased from 52 to 35 days (35% reduction). The best 90th percentile wait time decreased from 126 to 98 days (22% reduction). The overall increase in capacity could be explained in part by the significant increase in fast tracking from the ICU to the ward (> 2-fold) or bypassing the ICU altogether (4-fold increase reaching 13%). Despite these successes, challenges persist as the number of OR cancellations remained around 7.5% of all cases, mainly because of limited ICU resources. The NBHC-IHS partnership on this project has resulted in excellent engagement by stakeholders and promoted team cohesiveness. Furthermore, it has allowed significant reorganization and realignment of efforts to limit wait times and maximize overall capacity.

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium—with diverse expertise and representation—representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens’ values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource’s varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

The Coronavirus Disease 2019 Pandemic’s Effect on Critical Care Resources and Health-Care Providers: A Global Survey

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide.Research QuestionHow do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs?Study Design and MethodsBetween April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout.ResultsWe included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46).InterpretationOur findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.

Triage of ICU Resources in a Pandemic Surge: Good Ethics Depends on Good Data

Triage of ICU Resources in a Pandemic Surge: Good Ethics Depends on Good Data

Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria.

To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.

Weaning by Surgical Tracheostomy and Portable Ventilators Released ICU Ventilators During Coronavirus Disease 2019 Surge in London

Weaning by Surgical Tracheostomy and Portable Ventilators Released ICU Ventilators During Coronavirus Disease 2019 Surge in London

Coronavirus Disease 2019 Pandemic Measures: Reports From a National Survey of 9,120 ICU Clinicians.

Importance:Recent reports identify that among hospitalized coronavirus disease 2019 patients, 30% require ICU care. Understanding ICU resource needs remains an essential component of meeting current and projected needs of critically ill coronavirus disease 2019 patients.Objectives:This study queried U.S. ICU clinician perspectives on challenging aspects of care in managing coronavirus disease 2019 patients, current and anticipated resource demands, and personal stress.Design, Setting, and Participants:Using a descriptive survey methodology, an anonymous web-based survey was administered from April 7, 2020, to April 22, 2020 (email and newsletter) to query members of U.S. national critical care organizations.Measurements and Main Results:Through a 16-item descriptive questionnaire, ICU clinician perceptions were assessed regarding current and emerging critical ICU needs in managing the severe acute respiratory syndrome coronavirus 2 infected patients, resource levels, concerns about being exposed to severe acute respiratory syndrome coronavirus 2, and perceived level of personal stress. A total of 9,120 ICU clinicians responded to the survey, representing all 50 U.S. states, with 4,106 (56.9%) working in states with 20,000 or more coronavirus disease 2019 cases. The 7,317 respondents who indicated their profession included ICU nurses (n = 6,731, 91.3%), advanced practice providers (nurse practitioners and physician assistants; n = 334, 4.5%), physicians (n = 212, 2.9%), respiratory therapists (n = 31, 0.4%), and pharmacists (n = 30, 0.4%). A majority (n = 6,510, 88%) reported having cared for a patient with presumed or confirmed coronavirus disease 2019. The most critical ICU needs identified were personal protective equipment, specifically N95 respirator availability, and ICU staffing. Minimizing healthcare worker virus exposure during care was believed to be the most challenging aspect of coronavirus disease 2019 patient care (n = 2,323, 30.9%). Nurses report a high level of concern about exposing family members to severe acute respiratory syndrome coronavirus 2 (median score of 10 on 0–10 scale). Similarly, the level of concern reached the maximum score of 10 in ICU clinicians who had provided care to coronavirus disease 2019 patients.Conclusions:This national ICU clinician survey identifies continued concerns regarding personal protective equipment supplies with the chief issue being N95 respirator availability. As the pandemic continues, ICU clinicians anticipate a number of limited resources that may impact ICU care including personnel, capacity, and surge potential, as well as staff and subsequent family members exposure to severe acute respiratory syndrome coronavirus 2. These persistent concerns greatly magnify personal stress, offering a therapeutic target for professional organization and facility intervention efforts.