ICU Visitation Research Articles

Efficacy of Virtual Visitation in ICU During COVID-19 Pandemic: The ICU Visits Randomized Controlled Trial.

This study aimed to demonstrate the impact of virtual visits on the satisfaction of family members and the anxiety and depression of patients in the ICU during the COVID-19 pandemic. A single-center, randomized controlled trial. This study was conducted from July 2021 to May 2022, in the Seoul National University Hospital. A total of 40 patients eligible for virtual visitation whose Richmond Agitation-Sedation Scale score was -2 or above were recruited and randomized into virtual visitation and usual care groups. Virtual visitation began on the first day after ICU admission and continued until ICU discharge, lasting for a maximum of 7 days. The primary outcome was the satisfaction level of the family members with care and decision-making in the ICU, assessed using the Family Satisfaction-ICU (FS-ICU) 24-survey questionnaire. Secondary outcomes included patient anxiety and depression levels assessed using the Hospital Anxiety and Depression Scale (HADS), at the study enrollment after ICU admission and at the end of the study. After two patients were excluded due to clinical deterioration, 38 patients were ultimately analyzed, including 18 patients in the virtual visitation group and 20 patients in the usual care group. The FS-ICU 24 survey score was significantly higher in the virtual visitation group (89.1 ± 13.0 vs. 75.1 ± 17.7; p = 0.030). The reduction in HADS-Anxiety (59.4% vs. 15.39; p < 0.001) and HADS-Depression (64.5% vs. 24.2%; p < 0.001) scores between the two time points, from study enrollment after ICU admission to the end of the study was significantly larger in the virtual visitation group. In the COVID-19 pandemic era, virtual visits to ICU patients helped reduce depression and anxiety levels of patients and increase the satisfaction of their family members. Enhancing access to virtual visits for family members and developing a consistent approach may improve the quality of care during another pandemic.

Role of social determinants burden on outcomes and survival for AYAs with cancer.

1610 Background: Health care utilization and survival are correlated with social determinants of health (SDoH). Minimal data exists on the impact of SDoH within AYA Oncology. Methods: TriNetX, a de-identified healthcare research database retrospectively examined presence of SDoH billing codes among AYA cancer patients at various time points. Three cohorts were evaluated: ages &lt;15, 15-39, &gt;39. Cox proportional hazards regression was used to assess predictors of SDoH burden and survival in AYAs. Results: Baseline demographics were similar across cohorts. AYAs had higher baseline SDoH (25811, 5.2%) compared to &lt;15 (3913, 2.9%) and &gt;39 (58237, 1.8%). After diagnosis, AYAs had greater incidence of SDoH burden at 1y (OR 1.86 vs &lt;15, 2.71 vs &gt;39), 3y (OR 1.79 vs &lt;15, 2.63 vs &gt;39), and 5y (OR 1.8 vs &lt;15, 2.5 vs &gt;39). AYAs with any SDoH had higher occurrences of ED (OR 2.51) and ICU visits (OR 1.94). Within AYAs, baseline SDoH code was most prevalent in 30-39 age group, males, Hawaiian/Pacific Islanders, and lung cancers. The most common SDoH code in AYAs at diagnosis was homelessness at 57.8%. In a multivariate analysis examining incidence of SDoH in AYAs, positive associations were age 30-39; 1.95 (1.61-2.37), males; 1.49 (1.36-1.63), American Indian/Alaska Native; 4.44 (3.12-6.31), and presence of SDoH at diagnosis; 83.0 (71.6-96.3). Mortality in AYAs was associated with age 30-39; 1.81 (1.72-1.91), males; 1.58 (1.54-1.63), unknown race; 1.53 (1.48-1.58), and CNS tumors; 1.15 (1.06-1.25). Conclusions: AYAs with cancer have a high prevalence of SDoH burden at diagnosis and acquired. Within AYAs, age 30-39, males, and minority populations were most likely to acquire a SDoH code and have worse survival. The strongest association with both incidence of SDoH burden and mortality was a SDoH code at diagnosis. [Table: see text]

Tobacco Exposures are Associated With Healthcare Utilization and Healthcare Costs in Pregnant Persons and Their Newborn Babies.

Identifying healthcare utilization and costs associated with active and passive smoking during pregnancy could help improve health management strategies. Data are from the Newborn Epigenetics STudy (NEST), a birth cohort enrolled from 2005 to 2011 in Durham and adjacent counties in North Carolina, United States. Participants included those for whom prenatal serum samples were assayed and for whom administrative data were obtainable (N = 1045). Zero-inflated poisson regression models were used to assess associations between cotinine, adjusted for covariates (eg, race and ethnicity, age at delivery, cohabitation status, and education), and health care utilization outcomes. Generalized linear regression models were used to estimate average total charges. Simulation models were conducted to determine the economic benefits of reducing secondhand smoke and smoking during pregnancy. Increasing levels of cotinine were positively associated with parent's number of emergency department (ED) visits (coefficient[b] = 0.0012, standard error [SE] = 0.0002; p < .001), the number of ICU hours (b = 0.0079, SE = 0.0025; p = .002), time spent in the ICU (b = 0.0238, SE = 0.0020, p < .001), and the number of OP visits (b = 0.0003, SE = 0.0001; p < .001). For infants, higher cotinine levels were associated with higher number of ED (b = 0.0012, SE = 0.0004; p = .005), ICU (b = 0.0050, SE = 0.001; p < .001), and OP (b = 0.0006, SE = 0.0002; p < .001) visits and longer time spent in the ED (b = 0.0025, SE = 0.0003; p < .001), ICU (b = 0.0005, SE = 0.0001; p < .001), and IP (b = 0.0020, SE = 0.0002; p < .001). Simulation results showed that a 5% reduction in smoking would correspond to a potential median cost savings of $150 533 from ED visits of parents and infants. Our findings highlight the importance of smoke exposure cessation during pregnancy to reduce health care utilization and costs for both parents and infants. This study reinforces the importance of reducing smoking and secondhand smoke exposure during pregnancy. Focusing on expanding cessation services to this group could help reduce morbidities observed within this population. Furthermore, there is the potential for healthcare cost savings to healthcare systems, especially for those with high delivery numbers. These cost savings are represented by potential reductions in ED, OP, and ICU hours and visits.

Differential Host Response Contributing to Incidence of Arterial and Venous Thromboembolism at Index Hospitalization for Sars-Cov-2 Infection across Wuhan, Delta, Omicron and Omicron BA.x Variants

Introduction SARS-CoV-2 induced coagulopathy has been associated with increased risk of arterial and venous thromboembolism. Literature demonstrates that incidence of thromboembolism has varied widely throughout the COVID-19 pandemic, with many reports preceding emergence of Delta and Omicron variants. This study aimed to characterize the incidence of arterial and venous thromboembolic events among patients hospitalized with acute SARS-CoV-2 infection during Wuhan, Delta, Omicron, or Omicron BA.x waves. To our knowledge, this study debuts variant specific analyses to shed some light on reported substantive differences pooled across SARS-CoV-2 variants regarding host response, clinical course, and outcomes. Intensity of pathophysiologic anomalies may have been associated with macro- and micro-circulatory clotting. Therefore, we hypothesized variant idiosyncratic host responses would be evoked and aimed to link our patient's demographics and comorbidity patterns with risk of thromboembolism. Methods This is a retrospective study including patients with laboratory confirmed SARS-CoV-2 infection who underwent index hospitalization during Wuhan (March 14, 2020- June 18, 2021), Delta (June 19, 2021- December 18, 2021), Omicron (December 19-March 30, 2022) or Omicron BA.x (March 31, 2022 - April 14, 2023) variant waves at an 820-bed academic public health trust hospital in Florida. Demographics, laboratory at presentation, ICD-10-CM-based comorbidity, SARS-CoV-2 directed treatment and administrative data were extracted under IRB exemption from electronic medical records. Generalized regression with adaptive LASSO identified variables associated with embolism in at least one variant wave controlling for extant dysrhythmia, chronic anticoagulation therapy, and COVID-19 directed treatment. Prespecified 2-way ANOVA examined interactions between intra- vs. inter-variant waves but was ruled out due to strong imbalances in variation. Thus, only within-variant contrasts were performed. Continuous data summarized with mean [±SD] were compared using an ANOVA test adjusting p-value for parametric vs. non-parametric distribution. Discrete data summarized as proportions were compared with chi-squared test. A p&amp;lt;.05 was considered significant. Results We studied 6490 patients consecutively discharged across Wuhan (n=2249), Delta (n=1196), Omicron (n=953) and Omicron BA.x (n=2092) variants with respective embolic event(s) of 3%, 2%, 2%, and 4%. Table 1 summarizes demographics, anthropometric, comorbidities and laboratory biomarkers obtained within 24h of hospitalization across variants. Table 2 presents clinical course and outcomes. Discussion Incidence of embolic events was isomorphically distributed among waves tending to affect older males harboring hypertension, neurologic disease, and/or heart failure. D-dimer levels at presentation significantly distinguished risk of thromboembolism with Wuhan, Delta, or Omicron, but not Omicron BA.x variant infection. Indeed, Omicron BA.x infection was associated with numerically lower ICU visits, mechanical ventilation requirement, hospital LOS and mortality. Elevated D-dimer consistently has been associated with excess risk of progression to severe illness and mortality (Milenkovic M et al., 2022), mostly via pooled results across SARS-CoV variant waves. Some have suggested that D-dimer guided anticoagulation management improves outcomes in patients with COVID-19 (Ronderos Botero DM et al., 2023). Deeper phenotyping of patients infected with Omicron BA.x variants may reveal unique prothrombotic features driving what appears to be a less severe hypercoagulable state.

Real-World Analysis of the Underdiagnosis, Clinical Outcomes and Associated Burden of Hematopoietic Stem Cell Transplantation-Associated Thrombotic Microangiopathy (HSCT-TMA) in the United States of America

Background: Thrombotic microangiopathy (TMA) associated with hematopoietic stem cell transplantation (HSCT-TMA) is a serious post-transplant complication. HSCT-TMA is difficult to diagnose due to overlapping symptoms with other conditions and a lack of universally adopted diagnostic criteria. Objectives: This study aimed to assess the incidence and diagnosis of HSCT-TMA in real-world practice across the US, including possible missed diagnoses, alongside clinical outcomes and associated burden of HSCT-TMA. Methodology: This retrospective, observational study investigated the incidence of HSCT-TMA from July 2009-August 2020 using data from the TriNetX US Electronic Medical Record (EMR) database. Patients who underwent autologous or allogenic HSCT procedures and had conditioning regimens recorded were stratified into three cohorts: confirmed TMA, suspected TMA, and non-TMA patients. Confirmed TMA was defined as any individual with at least one recorded hemolytic uremic syndrome (HUS)/TMA diagnosis code within 12 months of HSCT. Suspected TMA included individuals without a recorded HUS/TMA ICD code, but who met the modified published criteria (Cho BS, et al. Transplantation 2010;90:918-26; Jodele S, et al. Transfus Apher Sci 2016;54:181-90) within 12 months of HSCT; published criteria were adapted to fit data available in the TriNetX database. Non-TMA patients did not meet criteria to be included in either of the previous two cohorts. Adult and pediatric patients were analyzed separately. Demographic and clinical characteristics at baseline, clinical outcomes, and all-cause unadjusted healthcare resource utilization within 12 months of HSCT, were assessed. The baseline period was defined as the six months before the index date (inclusive), unless specified; index date was defined as the date a patient had a HSCT procedure code recorded. Statistical comparisons, where conducted, were made against the non-TMA cohort using the Fisher's exact test for categorical variables, the student's t test for means, and the Mann-Whitney U test for medians. Significance was set at the level of p&amp;lt;0.05. Results: In total, 16,809 adult and 901 pediatric patients had an HSCT procedure code and a recorded conditioning regimen. The confirmed TMA group comprised 125 (0.7%) adult and 30 (3.3%) pediatric patients, the suspected TMA group included 3,029 (18.0%) adult and 94 (10.4%) pediatric patients, and the non-TMA group included 13,655 (81.2%) adult and 777 (86.2%) pediatric patients. Baseline demographics were similar across all groups. Mortality within the first year of HSCT was significantly higher in adult patients with confirmed TMA (40.0%) and suspected TMA (30.7%) compared with patients without TMA (13.6%). Mortality was numerically highest in pediatric patients with confirmed TMA (26.7%) followed by suspected TMA (23.4%), and lowest in non-TMA patients (15.8%). Comorbidity impact (based on the Charlson Comorbidity Index) was significantly higher, and HSCT complications significantly more common, in confirmed and suspected TMA patients (Table 1). Clinical outcomes in the first year after HSCT were significantly worse in confirmed and suspected TMA patients than in non-TMA patients (Table 2). All patients with confirmed and suspected TMA had a significantly higher frequency of oxygen/intubation compared with non-TMA patients. Dialysis rates were significantly higher in all patients with confirmed TMA (adults, 26.4%; pediatrics, 20.0%) and adult patients with suspected TMA (6.9%), compared with patients with no TMA (adults, 2.2%; pediatrics, 4.0%); pediatric patients with suspected TMA (8.5%) had numerically higher dialysis rates compared with those without TMA (4.0%). Patients with confirmed and suspected TMA had significantly greater use of targeted therapies and a higher number of total ICU visits, compared with non-TMA patients (Table 2). Conclusions: This study showed that HSCT-TMA is associated with a high mortality and morbidity burden. Furthermore, these results suggest that HSCT-TMA is underdiagnosed in the real-world setting, as patients with suspected TMA had worse outcomes and a higher burden of disease than patients without TMA following HSCT. This study highlights the need for timely diagnosis of this severe complication, as well as novel approaches to treat and manage this vulnerable population.

A family intervention to prevent postoperative delirium in patients undergoing cardiac valve surgery: A randomized controlled study

BackgroundMultiple guidelines recommend that families be involved in the care of ICU patients, which has been widely used in ICU delirium management in recent years. Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with poor outcomes; however, the effects of family intervention on this group are rarely studied. ObjectivesThis study aimed to investigate the effects of family intervention on the incidence of POD and the ICU prognoses of patients undergoing cardiac valve surgery. MethodsThis was a two-group, single-blind, randomized controlled trial involving 80 patients undergoing cardiac valve surgery, with 40 patients in each group. The control group received routine ICU visits, and the experimental group implemented a family intervention that instructed family caregivers to participate in delirium management during ICU visits. The occurrence of POD, ICU stay, mechanical ventilation time of patients; as well as the anxiety, depression, and satisfaction levels of family caregivers were compared between the two groups. ResultsThe incidence of POD and ICU stay of patients were significantly lower in the experimental group compared to the control group (P < 0.05). The anxiety and depression incidence of family caregivers in the experimental group was lower than those of the control group (P < 0.05), and satisfaction scores were higher than those of the control group (P < 0.05). ConclusionsFamily intervention has the potential to reduce the incidence of POD in patients undergoing cardiac valve surgery, shorten ICU stays, reduce the incidence of anxiety and depression in family caregivers, and improve their satisfaction. These findings suggest that family intervention could be incorporated into routine nursing practice.

375. RURAL PATIENTS HAVE A PROLONGED INPATIENT RECOVERY PROCESS AFTER ESOPHAGECTOMY COMPARED TO NON-RURAL PATIENTS AT A HIGH-VOLUME ESOPHAGEAL PROGRAM

Abstract Background Geographic access to care plays a large role in health disparities in esophageal cancer care, with rural individuals often travelling further to access complex healthcare services. We sought to characterize peri-operative outcomes in patients undergoing esophagectomy for loco-regional cancer at a single academic tertiary care center based on geographic home location. We hypothesize that rural patients will have worse peri-operative outcomes after esophagectomy, despite receiving care at the same high-volume hospital. Methods Prospectively collected data from patients with loco-regional esophageal cancer who underwent esophagectomy at a single academic medical center between 2003 to 2022 were analyzed based on county. The counties were aggregated into previously existing state-level ‘metropolitan’ versus ‘rural’ designations per the Rural Health Information Hub guidelines. Distance traveled by the patients were calculated using driving distance between the patient’s reported zip code and hospital address. Demographics, pre-operative treatment, surgical complications, post-operative outcomes, length of stay (LOS), and mortality of the two groups were analyzed using chi-squared, paired t-tests, and single-factor ANOVA. Results The cohort consisted of 1545 patients with 76.0% from metropolitan counties and 24.0% from rural counties. Patients were more likely to be male in both groups (p = 0.004), with no significant differences in pre-operative characteristics. Both groups had similar rates of pre-operative chemotherapy (p = 0.11) and pre-operative radiation (p = 0.58). Rural patients traveled greater distances for healthcare services compared to metropolitan patients (rural: 192.4 ± 101.2 miles; metropolitan: 63.4 ± 36.7 miles; p &amp;lt; 0.001). Post-operatively rural patients had higher rates of pneumonia (p = 0.04) and more initial ICU visits (p &amp;lt; 0.001). Rural patients had longer ICU LOS (p &amp;lt; 0.001), but no difference in total hospital LOS (p = 0.28) or 30-day mortality (p = 0.35). Conclusion Rural patients tended to have a more complex inpatient recovery process after esophagectomy despite receiving surgery at the same high-volume institution and no differences in pre-operative characteristics (BMI, smoking history, and co-morbidities). It is unclear as to the reason for differences in pneumonia rates and ICU stays. Future studies should focus on the impact of rural location on disparities for individuals undergoing esophagectomy.

Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study.

During the pandemic, traditional family meetings were replaced by remote telecommunications. We assessed the families' satisfaction with these communications using a survey-based questionnaire. The study involved 20-minute telephonic surveys conducted with the family member who was updated during the hospitalization of the patient. A thematic-based questionnaire with responses on a scale of 5 ranging from very dissatisfied to very satisfied was used. The responses were dichotomized into bad and good reports for analysis. A total of 196 patients were eligible. Only 154 patients' family representatives consented to the study. The frequency and content of the telephonic updates were satisfactory. The bad report was assigned to 5% of families only. Among features assessing empathy of communication providers, the satisfaction rate was much higher with 3% of families alone providing a bad report. The response was significantly biased against the final outcome of the patient with poor review often provided by relatives of patients who had succumbed to the illness. The dissatisfaction rate was much higher, above 12% for the trust of communication and ICU visitation. However, the final outcome of the patient did not affect the trust in the information conveyed by the physician. This study highlights several drawbacks in the communication strategy during the second surge of coronavirus disease-2019 (COVID-19). The final outcome of the patient was the key decisive factor for the response to most of the questionnaire. Sustained faith in communication by the physician despite the final outcome of the patient, re-emphasizes the need for emotional connection and training for breaking bad news. Varghese MP, Selwyn T, Nair S, Samuel S, Chacko B, Pichamuthu K. Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study. Indian J Crit Care Med 2023;27(8):537-544.

Family members' perceptions of counselling during visits to loved ones in an adult ICU.

The study's aims were to (1) assess family members' perceptions of the quality of the counselling they received while visiting a loved one in an adult ICU and (2) identify factors that influence family members' perceptions of counselling quality. A cross-sectional survey of visiting family members of adult ICU patients. Family members (n = 55) at eight ICUs across five Finnish university hospitals completed a cross-sectional survey. Family members assessed the quality of counselling in adult ICUs to be good. Factors associated with the quality of counselling were knowledge, family-centred counselling, and interaction. Family members' ability to live normally was associated with understanding of the loved one's situation (ρ = 0.715, p < 0.001). Interaction was associated with understanding (ρ = 0.715, p < 0.001). Family members felt that intensive care professionals did not adequately ensure that they understood counselling-related issues and that they lacked opportunities to give feedback, in 29% of cases, staff asked the family members whether they understood the counselling and 43% of family members had opportunities to offer feedback. However, the family members felt that the counselling they received during ICU visits was beneficial.

CURRENT APPLICATIONS OF PATIENT COMMUNICATION TECHNOLOGIES IN GERIATRIC CRITICAL CARE

Abstract The availability and utility of patient-centered communication technologies in acute-critical care settings have evolved slowly over the past 30 years with wide variability, little standardization, and few randomized controlled clinical trials (RCT). The COVID-19 pandemic forced rapid expansion and use of communication technologies, particularly between patients and remote family caregivers. To capture changes responsive to the pandemic, this paper reviews current literature (&amp;lt; 5 years) on communication technologies in acute-critical care settings focusing on the user experience among older adult patients. We supplement these findings with case-based evidence from a pilot RCT of an electronic tablet communication application provisioned to mechanically ventilated ICU patients, and efforts toward hospital-wide implementation. Recent literature on patient communication technology consists primarily of qualitative, descriptive accounts of video communication (i.e., ICU visits) or provision of augmentative and alternative communication. Recommendations for required skills, standardization, and research regarding patient communication technology are provided.

Visitors not Welcome: Hospital Visitation Restrictions and Institutional Betrayal

Healthcare organizations’ continued restrictions on hospital visitation during the COVID-19 pandemic can be considered a violation of the rights of hospitalized patients to receive family visitors. Despite expert opinion related to the safety of visitation and low risk of visitor transmission with appropriate monitoring and precautions, hospital visitation restrictions have continued beyond the initial crisis phase of the pandemic, with little transparency or inclusion of key stakeholders in the decision-making process. Particularly on critical care units, blocking access to family visitors can contribute to additional harm and trauma for care-dependent hospitalized patients and their families. Utilizing an institutional betrayal framework, the aim of this commentary on hospital ICU visitation policy is to provide a discussion of how hospitals who serve a care-dependent population have placed critically ill patients, families, and healthcare workers at risk for complex trauma. Hospital social workers should incorporate an integrated social work approach to advocacy efforts which address not only individual hospitalized patient service needs, but also the uneven power differential that can contribute to inequity in visitation, medical mistrust, and long-term community trauma. On the interprofessional ICU team, social workers can function as trauma informed systems experts, coordinating and facilitating supports to help patients and families cope with hospitalization, while also advocating within their institution and with elected officials for policy change to protect patient and family–centered visitation rights.

Non-pharmacological delirium prevention practices among critical care nurses: a qualitative study

BackgroundDelirium is common among critically ill patients, leading to increased mortality, physical dependence, and cognitive impairment. Evidence suggests non-pharmacological delirium prevention practices are effective in preventing delirium. However, only a few studies explore the actual implementation and its associated challenges among critical care nurses.AimTo explore critical care nurses’ perceptions of current non-pharmacological delirium prevention practices in adult intensive care settings, including delirium screening, early mobilisation, sleep promotion, family engagement, and sensory stimulation.MethodsA qualitative design adopting a thematic analysis approach. Semi-structured interviews with 20 critical care nurses were conducted in ten acute hospitals in mainland China.ResultsThree themes emerged: (a) importance of family engagement; (b) influence of organisational factors, and (c) suggestions on implementation. The implementation of non-pharmacological delirium prevention practices was limited by a strict ICU visitation policy, lack of routine delirium screening and delirium training, light and noise disturbances during nighttime hours, frequent resuscitation and new admissions and strict visitation policy. Case-based training, adopting a sensory stimulation protocol, and family engagement may be enablers.ConclusionICU care routine that lacks delirium assessment and the strict family visitation policy made it challenging to implement the complete bundle of non-pharmacological practices. Resource deficiency (understaffing, lack of training) and ICU environment (frequent resuscitation) also limited the implementation of non-pharmacological practices. Clinicians could implement case-based training and sensory-stimulation programs and improve communication with family caregivers by instructing family caregivers to recognise delirium symptoms and delirium prevention strategies.

Video calls did not reduce PTSD symptoms in relatives during restricted ICU visits in the COVID-19 pandemic

To help reduce the spread of the SARS-CoV-2 virus during the COVID-19 pandemic, ICU visits were banned or restricted. Therefore, family-centered care as usually practiced was not feasible Video calls were recommended to meet relatives’ needs. The aim of this study was to investigate the effect of video calls on symptoms of post-traumatic stress disorder (PTSD) in relatives of ICU patients. This single-center study was performed during the first wave (15.03.2020‒30.04.2020; visits banned) and the second wave (01.10.20‒08.02.21: visits restricted) of the COVID-19 pandemic. The Impact of Event Scale-Revised (IES-R) was used to assess PTSD symptoms and an adapted version of the Family Satisfaction in the Intensive Care Unit 24-Item-Revised questionnaire (aFS-ICU 24R) to assess family satisfaction 3 months after ICU stay. The primary outcome was the difference in IES-R score at 3 months between the video call group (VCG) and the standard care group (SCG, no video calls). In addition, inductive content analysis of relatives’ comments regarding their satisfaction with decision-making and ICU care was performed. Fifty-two relatives (VCG: n = 26, SCG: n = 26) were included in this study. No significant difference in IES-R scores was observed between the VCG and the SCG (49.52 ± 13.41 vs. 47.46 ± 10.43, p = 0.54). During the ICU stay (mean 12 days, range 5.25‒18.75 days), the members of the VCG made a median of 3 (IQR 1‒10.75) video calls. No difference between the groups was found for conventional telephone calls during the same period (VCG: 9 calls, IQR 3.75‒18.1; SCG: 5 calls, IQR 3‒9; p = 0.12). The aFS-ICU 24R scores were high for both groups: 38 (IQR 37‒40) in the VCG and 40 (IQR 37‒40: p = 0.24) in the SCG. Video calls appeared largely ineffective in reducing PTSD symptoms or improving satisfaction among relatives affected by banning/restriction of ICU visits during the COVID-19 pandemic. Further investigations are needed to acquire more data on the factors involved in PTSD symptoms experienced by relatives of ICU patients during the COVID-19 pandemic.

PB2219: A REAL-WORLD EXPERIENCE WITH HEALTHCARE RESOURCE UTILIZATION PATTERNS AND RELATED COSTS IN PATIENTS WITH SICKLE CELL DISEASE IN NORTH LEBANON

Background: Sickle cell disease (SCD) remains associated with high healthcare resource utilization (HRU), despite a reduction in morbidity and mortality associated with the use of disease-modifying therapies, mostly because of vaso-occlusive crises (VOC). In Lebanon, there are limited national estimates on HRU, cost of medical care, and treatment expenditures for patients with SCD. A better understanding of these estimates may provide new perspectives to improve access to high-quality cost-effective health care services. Aims: Aim of our study is to evaluate patterns of HRU and related cost in a cohort of patients with SCD receiving care in a Comprehensive SCD referral center at NINI hospital in North Lebanon. Methods: An observational, non-interventional, retrospective study of 136 patients (54.4% females) with confirmed diagnosis of SCD was conducted in North Lebanon. Data on HRU, including ED visits, ambulatory visits, and hospitalizations, was collected in a patient health information (PHI)-anonymized format from patients’ paper and electronic medical files, as well as hospital and ED files, from May 1, 2018 to April 30, 2020. Uncomplicated VOCs were defined as pain crises, whereas complicated VOCs were defined as acute chest syndrome, acute splenic sequestration, acute hepatic sequestration or priapism. The annual rate of HRU visits was calculated as a ratio of the total number of visits to the total number of years of follow-up across all patients. Based on the available data, the average yearly cost was determined as the ratio of the total cost of these visits to the total number of years of follow-up. Results: The median age of patients in this study was 10.8 years (IQR 5.3 to 19.6 years) at the time of investigation. Majority of patients were diagnosed with SS (72.1%) and Sβ0 (21.3%) genotype across all age groups. The most prevalent SCD-related complications were pain crisis (90.4%), fever (43.4%), acute chest syndrome (33.1%), and acute splenic sequestration (22.8%). Most of hospitalizations, ICU visits, and ED visits in adult patients (age >16 years) were due to uncomplicated VOCs. The average annual costs of HRU were 8,270,920 Lebanese pounds (LBP) amounting to 5,514 USD (per patient per year) of which 92.1% was for hospitalizations, 4% for ED visits and 3.9% for ambulatory visits. Uncomplicated VOCs had the highest annual costs for ED, ICU and hospitalizations. Costs related to medications, diagnostics, non-hematologist medical consults, uncompensated care and lost productivity are not included in this analysis. Analgesics, folic acid and hydroxyurea were the most commonly prescribed drugs across all age categories, with hydroxyurea being prescribed to 84% of patients. Image:Summary/Conclusion: SCD and associated complications resulted in significant acute HRU, according to this real world study. VOCs continues to be most important factor for resource use, ICU admission and costs, with hospitalizations accounting for majority of annual costs. Despite the high HRU rate in this relatively young SCD cohort, the cost of HRU in a comprehensive setting with effective outpatient management as that in North Lebanon appears affordable for the health care system. However when additional SCD related and non SCD related costs of care are factored in, the economic burden of SCD care is likely to be far higher than the figures presented here.

Associations between the Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative and Quality of Care at the End of Life.

Background: In 2017, Veterans Health Administration (VHA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) to promote goals-of-care conversations (GoCC) between seriously ill patients and their practitioners, to document patient preferences in the electronic health record, and to provide care consistent with patients' goals. Objectives: We evaluated the associations between this initiative and quality of care in the last month of life (i.e., emergency department/intensive care unit [ED/ICU] visits and hospice consultations). Design: We conducted patient-level propensity score analyses to evaluate the associations between LSTDI and care utilization in the last 30 days of life. The primary exposure was a three-level factor: no GoCC (reference group), GoCC with Full Code, and GoCC with do not resuscitate (DNR). The outcomes were ED/ICU visits and hospice consultations within 30 days of death. Setting/Subjects: A total of 44,320 patients receiving care in Veterans (VA), who were older than 18, and who died and had a completed encounter within 24 months of death in a VA primary care, mental health, or medical specialty between January 2017 and December 2019. Results: Patients with a documented GoCC and DNR code status had decreased risk of ED visits (odds ratio [OR] = 0.6, 89% credible intervals [CI] = [0.57-0.64]) and ICU visits (OR = 0.49, 89% CI = [0.45-0.53]), and increased rates of hospice visits (β = 2.18, 89% CI = [2.11-2.26]) compared with patients with no GoCC. Conclusion: The LSTDI had a positive impact by eliciting and documenting patient preferences for care at the end of life and quality of care in the last month of life. We observed associations between care preferences and ED/ICU visits and hospice consultations within 30 days of death. Further research should address the associations between LSTDI and use of palliative care, and outcomes associated with limits to specific life-sustaining treatments such as mechanical ventilation, artificial nutrition, and hydration.

P127: HEALTHCARE RESOURCE UTILIZATION PATTERNS AND RELATED COSTS IN PATIENTS WITH SICKLE CELL DISEASE IN NORTH LEBANON- A REAL-WORLD EXPERIENCE

Background: Despite a reduction in morbidity and mortality associated with the use of disease modifying therapies, sickle cell disease (SCD) remains associated with high healthcare resource utilization (HRU), primarily attributed to vaso-occlusive crisis (VOC). (1, 2) There are limited national estimates on HRU, cost of medical care, and treatment expenditures for patients with SCD in Lebanon. A better understanding of these estimates may provide new perspectives to improve access to high-quality cost-effective health care services. Aims: We aimed to evaluate patterns of HRU and related cost in a cohort of patients with SCD receiving care in a Comprehensive SCD referral center at NINI hospital in North Lebanon. Methods: A retrospective non-interventional observational study was conducted among 136 patients (54.4% females) with confirmed diagnosis of SCD in North Lebanon. Data on HRU including emergency department (ED) visits, ambulatory visits and hospitalizations collected in a patient health information (PHI)-anonymized format during the period 01 May2018 - 30 Apr 2020 were obtained from patients’ paper and electronic medical files, as well as hospital and ED files. Uncomplicated VOCs were defined as pain crises, whereas complicated VOCs were defined as acute chest syndrome, acute splenic sequestration, acute hepatic sequestration or priapism. The annual rate of HRU visits was calculated as a ratio of the total number of visits to the total number of years of follow-up across all patients. The average annual cost was similarly calculated as the ratio of total cost of these visits to the total number of years of follow-up, based on available data. Results: In the present study, the median age of patients at the time of study was 10.8 years (IQR 5.3 to 19.6 years). Majority of patients were diagnosed with SS (72.1%) and Sβ0 (21.3%) genotype across all age groups. Pain crisis (90.4%), fever (43.4%), acute chest syndrome (33.1%), and acute splenic sequestration (22.8%) were the most common SCD-related complications. The annual rate of HRU visits (per patient) was 5.7. Uncomplicated VOCs led to majority of hospitalizations, ICU and ED visits in adult patients (age >16 years). The average annual costs of HRU were 8,270,920 Lebanese pounds (LBP) amounting to 5,514 USD (per patient per year) of which 92.1% was for hospitalizations, 4% for ED visits and 3.9% for ambulatory visits. Annual costs for ED, ICU and hospitalizations were highest for uncomplicated VOC. Costs related to medications, diagnostics, non-hematologist medical consults, uncompensated care and lost productivity are not included in this analysis. Analgesics, folic acid and hydroxyurea were the most frequently administered medications across all age groups with 84% of patients being treated with hydroxyurea. Conclusion: This real world study reveals that SCD and its related complications resulted in significant acute HRU. VOCs remain the primary factor for resource use, ICU admission and costs with the largest proportion of annual cost being attributed to hospitalizations. Despite the high HRU rate in this relatively young SCD cohort, the cost of HRU in a comprehensive setting with effective outpatient management as that in North Lebanon appears affordable for the health care system. However when additional SCD related and non SCD related costs of care are included, the economic burden of SCD care is likely to be significantly higher than the figures reported.

Anxiety, depression, and end-of-life care utilization in adults with metastatic cancer.

End-of-life care for patients with cancer is often overly burdensome, and palliative and hospice care are underutilized. The objective of this study was to evaluate whether the mental health diagnoses of anxiety and depression were associated with variation in end-of-life care in metastatic cancer. This study used electronic health data from 1,333 adults with metastatic cancer who received care at two academic health centers in Louisiana, USA, and died between 1/1/2011-12/31/2017. The study used descriptive statistics to characterize the sample and logistic regression to examine whether anxiety and depression diagnoses in the six months before death were associated with utilization outcomes (chemotherapy, intensive care unit [ICU] visits, emergency department visits, mechanical ventilation, inpatient hospitalization, palliative care encounters, and hospice utilization), while controlling for key demographic and health covariates. Patients (56.1% male; 65.6% White, 31.1% Black) commonly experienced depression (23.9%) and anxiety (27.2%) disorders within six months of death. Anxiety was associated with an increased likelihood of chemotherapy (odds ratio [OR]=1.42, p=0.016), ICU visits (OR=1.40, p=0.013), and inpatient hospitalizations (OR=1.85, p<0.001) in the 30 days before death. Anxiety (OR=1.95, p<0.001) and depression (OR=1.34, p=0.038) were associated with a greater likelihood of a palliative encounter. Patients with metastatic cancer who had an anxiety disorder were more likely to have burdensome end-of-life care, including chemotherapy, ICU visits, and inpatient hospitalizations in the 30 days before death. Depression and anxiety both increased the odds of palliative encounters. These results emphasize the importance of mental health considerations in end-of-life care.

Effects of Liberal Visitation on Anxiety, Satisfaction, and Length of Stay Among Intensive Care Unit Patients

Several organizations recommended liberalization of ICU visits; however, the majority of the ICUs maintained restrictive visitation causing further lower social support to critically ill patients. The objective of the study is to determine the effects of Patient-Centered Liberal Visitation in the patients’ level of anxiety, satisfaction, and ICU length of stay. The study used a quasi- experimental, non-equivalent control group before-after design. It was conducted in an ICU in North America for a 5-month period using validated instruments. The study utilized consecutive sampling, 30 patients for the control and 30 for the intervention group. The control group had restricted visitation, wherein ICU visits were limited to specific hours per day. Patient- centered liberal visitation based on Levine’s Conservation Principles was implemented on the intervention group where visitations in ICU were more flexible. The study was approved by the Ethical Review Board. Sixty participants were included in the study with no significant difference when control and intervention group were clustered according to age (t=0.591, p=0.557), gender (X2= 0.069, p=0.793), marital status (X2= 5.524, p=0.137) and ethnicity (X2= 1.024, p=0.795). A significant difference within the intervention group’s pre-test and post-test Faces Anxiety Scale (FAS) Score (t=4.287, p=0.000) was noted. Similarly, the study found significant difference within the intervention group’s pre-test and post-test overall 6-item State Anxiety Inventory (SAI) Score (t=4.774, p=0.000). Pre-test anxiety scores in the intervention group were higher compared to post-test anxiety scores. Furthermore, a significant difference (t=3.831, p=0.000) was noted on patient satisfaction. The result showed higher patient satisfaction among the participants in the intervention group (4.73, SD 0.521) compared to the control group (3.97, SD 0.964). Lastly, when measuring the participants’ length of stay, no significant difference (t=-0.397, p=0.693) was noted. Patient-centered liberal visitation in the ICU decreases the patients level of anxiety and improves patient satisfaction.

Parental perception of neonatal ICU visitation during the COVID-19 pandemic.

SynopsisActions and efforts to promote strategies, such as psychiatric teleconsultation or debriefing of parents who have their babies in neonatal intensive care units, are needed to mitigate psychological distress.

ICU Survival Prediction Incorporating Test-Time Augmentation to Improve the Accuracy of Ensemble-Based Models

This work presents a novel method for applying test-time augmentation (TTA) to tabular data. We used TTA along with an ensemble of 42 models to achieve higher performance on the MIT Global Open Source Severity of Illness Score dataset consisting of 131,051 ICU visits and outcomes. This method achieved an AUC of 0.915 on the private test set (19,669 admissions) and won first place at Stanford University's WiDS Datathon 2020 challenge on Kaggle, while the Acute Physiology and Chronic Health Evaluation (APACHE) IV model (commonly used for ICU survival prediction in the literature) achieved an AUC of 0.868. In addition to increasing the AUC score, our method also reduces “unfair” bias.