Intensive Care Capacity Research Articles

Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

BackgroundThe SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic.MethodsA web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine.Results367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis.ConclusionsThe SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years.

What Should Be Design, Organization and Role of Pandemic Hospitals in COVID-19 Infection?

Introduction The aim of this study was to evaluate the physical structure, design, management, and organization of two emergency hospitals built in Istanbul within 45 days in the COVID-19 pandemic and the role played by these hospitals during the pandemic. A further aim was to determine the advantages and disadvantages of the emergency hospitals by comparing them with similar organizational models in other countries. Methods The pandemic hospitals established for the COVID-19 pandemic in Istanbul were investigated in a multi-faceted manner. The parameters investigated were physical structure, bed, and intensive care capacity, mechanics and infrastructure, medical equipment, personnel, organizational structures and management, and the medical services provided by both emergency hospitals during the outbreak. Results The pandemic hospitals were built on an open area of 125.000 m2 as a hospital building of 75.150 m2. Each hospital has a total bed capacity of 1008, with 576 being clinical and 432 being intensive care beds. The management of the pandemic hospitals is connected to two different hospital management structures, which are experienced in disasters and have all kinds of training, research clinics and academic personnel in this regard. Conclusion The healthcare services provided by both the pandemic hospitals fulfilled the purpose of those hospitals during the pandemic. As it is most likely that the world will face other serious disasters and epidemics in the future, the construction of multi-purpose and permanent emergency hospitals instead of emergency temporary hospitals would be more advantageous in terms of economy, medical service, and environment.

Nine Maternal Mortalities in 2 Weeks of Second COVID-19 Surge in Indonesia: A Case Series from One Large Tertiary Center

BACKGROUND: The fluctuating COVID-19 cases among the pregnant women’s population encountered increased of cases and maternal mortality. AIM: This research aimed to describe the case of maternal deaths caused by COVID-19. CASE REPORT: We present nine serial cases of maternal death caused by COVID-19 who were admitted to Dr. Soetomo General Academic Hospital for 14 days in June. We found 32 positive COVID-19 obstetric cases and reported nine maternal deaths with a fatality rate of up to 28%. Seven of nine patients had reverse transcription-polymerase chain reaction–confirmed SARS-CoV-2 infection, while two had a positive antigen swab. Half of the patients ≥35 years old, and five of nine patients had Class I obesity as preexisting comorbidity. This study reported the death of pregnant woman at their 2nd trimester and 3rd trimester presenting infected by severe COVID-19. The usual symptoms are dyspnea, cough, fever, and decreased consciousness. The result of chest X-ray examination among eight patients showed bilateral pneumonia. Most of cases were referrals from a secondary hospital due to overload hospital capacity. Three patients were directly transferred to the tertiary hospital without receiving initial treatment. Eight of 9 patients (88.9%) were transferred to intensive care unit and intubated due to low oxygen saturation. CONCLUSION: In conclusion, the limited hospital facility and lack of intensive care capacity for obstetric cases during the second wave of the COVID-19 pandemic may enhance the probability of mortality and morbidity in pregnant women infected by COVID-19.

Radiological findings in low-dose CT for COVID-19 pneumonia in 182 patients: Correlation of signs and severity with patient outcome.

To characterize computed tomography (CT) findings of coronavirus disease 2019 (COVID-19) pneumonia and their value in outcome prediction.Chest CTs of 182 patients with a confirmed diagnosis of COVID-19 infection by real-time reverse transcription polymerase chain reaction were evaluated for the presence of CT-abnormalities and their frequency. Regarding the patient outcome each patient was categorized in 5 progressive stages and the duration of hospitalization was determined. Regression analysis was performed to find which CT findings are predictive for patient outcome and to assess prognostic factors for the hospitalization duration.Multivariate statistical analysis confirmed a higher age (OR = 1.023, P = .025), a higher total visual severity score (OR = 1.038, P = .002) and the presence of crazy paving (OR = 2.160, P = .034) as predictive parameters for patient outcome. A higher total visual severity score (+0.134 days; P = .012) and the presence of pleural effusion (+13.985 days, P = 0.005) were predictive parameters for a longer hospitalization duration. Moreover, a higher sensitivity of chest CT (false negatives 10.4%; true positives 78.6%) in comparison to real-time reverse transcription polymerase chain reaction was obtained.An increasing percentage of lung opacity as well as the presence of crazy paving and a higher age are associated with a worse patient outcome. The presence of a higher total visual severity score and pleural effusion are significant predictors for a longer hospitalization duration. These results are underscoring the value of chest CT as a diagnostic and prognostic tool in the pandemic outbreak of COVID-19, to facilitate fast detection and to preserve the limited (intensive) care capacity only for the most vulnerable patients.

COVID-19 and critical care capacity: Can we mitigate demand?

COVID-19 and critical care capacity: Can we mitigate demand?

Infrastructure Availability for the Care of Congenital Heart Disease Patients and Its Influence on Case Volume, Complexity and Access Among Healthcare Institutions in 17 Middle-Income Countries.

The care for patients with congenital heart disease (CHD) is multi-disciplinary and resource intensive. There is limited information about the infrastructure available among programs that care for CHD patients in low and middle-income countries (LMIC). A survey covering the entire care-pathway for CHD, from initial assessment to inpatient care and outpatient follow-up, was administered to institutions participating in the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC). Surgical case complexity-mix was collected from the IQIC registry and estimated surgical capacity requirement was based on population data. The statistical association of selected infrastructure with case volume, case-complexity and percentage of estimated case-burden actually treated, was analyzed. Thirty-seven healthcare institutions in seventeen countries with median annual surgical volume of 361 (41–3503) operations completed the survey. There was a median of two (1–16) operating room/s (OR), nine (2–80) intensive care unit (ICU) beds, three (1–20) cardiac surgeons, five (3–30) OR nurses, four (2–35) anesthesiologists, four (1–25) perfusionists, 28 (5–194) ICU nurses, six (0–30) cardiologists and three (1–15) interventional cardiologists. Higher surgical volume was associated with higher OR availability (p = 0.007), number of surgeons (p = 0.002), OR nurses (0.008), anesthesiologists (p = 0.04), perfusionists (p = 0.001), ICU nurses (p < 0.001), years of experience of the most senior surgeon (p = 0.03) or cardiologist (p = 0.05), and ICU bed capacity (p = 0.001). Location in an upper-middle income country (P = 0.04), OR availability (p = 0.02), and number of cardiologists (p = 0.004) were associated with performing a higher percentage of complex cases. This study demonstrates an overall deficit in the infrastructure available for the care of CHD patients among the participating institutions. While there is considerable variation across institutions surveyed, deficits in infrastructure that requires long-term investment like operating rooms, intensive care capacity, and availability of trained staff, are associated with reduced surgical capacity and access to CHD care.

The Virtual Hospital: An Innovative Solution for Disaster Response.

Like any disaster, the COVID-19 pandemic has presented significant challenges to healthcare systems, especially the threat of insufficient bed capacity and resources. Hospitals have been required to plan for and implement innovative approaches to expand hospital inpatient and intensive care capacity. This article presents how one of the largest healthcare systems in the United States leveraged existing technology infrastructure to create a virtual hospital that extended care beyond the walls of the "brick and mortar" hospital.

Clinical Course and Outcome of Patients with SARS-CoV-2 Alpha Variant Infection Compared to Patients with SARS-CoV-2 Wild-Type Infection Admitted to the ICU.

The alpha variant of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is associated with higher transmissibility and possibly higher mortality compared with wild-type SARS-CoV-2. However, few data are available on the clinical course of infections with the alpha variant compared with wild-type SARS-CoV-2 in critically ill patients in intensive care units (ICUs). Therefore, we retrospectively analyzed patients admitted to our ICU due to SARS-CoV-2 Alpha variant infection and compared characteristics and course to patients with SARS-CoV-2 wild-type infection. The median age of patients with Alpha variant infections was 57 years compared to 62 years in the wild-type group. ICU survival was 41/80 (51%) in the Alpha variant group and 35/80 (44%) in the wild-type group (p = 0.429). Results of a matched-pair analysis based on age and sex illustrated that 45/58 patients (77.6%) in the Alpha variant group and 38/58 (65.5%) patients in the wild-type group required mechanical ventilation (p = 0.217). ICU survival was documented for 28/58 patients (48.3%) in the Alpha variant group and 27/58 patients (46.6%) in the wild-type group (p = 1). Thus, ICU mortality among patients with SARS-CoV-2 infections remains high. Although the Alpha variant group included younger patients requiring mechanical ventilation, no significant differences between patients with the SARS-CoV-2 Alpha variant and the SARS-CoV-2 wild-type, respectively, were detected with respect to clinical course and ICU mortality. For future VOCs, we believe it would be important to obtain valid and rapid data on the clinical course of critically ill patients who test positive for COVID-19 in order to perform appropriate epidemiological planning of intensive care capacity.

Outcomes and characteristics of COVID-19 patients treated with continuous positive airway pressure/high-flow nasal oxygen outside the intensive care setting.

BackgroundContinuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been used to manage hypoxaemic respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. Limited data are available for patients treated with noninvasive respiratory support outside of the intensive care setting.MethodsIn this single-centre observational study we observed the characteristics, physiological observations, laboratory tests and outcomes of all consecutive patients with COVID-19 pneumonia between April 2020 and March 2021 treated with noninvasive respiratory support outside of the intensive care setting.ResultsWe report the outcomes of 140 patients (mean±sd age: 71.2±11.1, 65% male (n=91)) treated with CPAP/HFNO outside of the intensive care setting. Overall mortality was 59% and was higher in those deemed unsuitable for mechanical ventilation (72%). The mean age of survivors was significantly lower than those who died (66.1 versus 74.4 years, p<0.001). Those who survived their admission also had a significantly lower median Clinical Frailty Score than the non-survivor group (2 versus 4, p<0.001). We report no significant difference in mortality between those treated with CPAP (n=92, mortality: 60%) or HFNO (n=48, mortality: 56%). Treatment was well tolerated in 86% of patients receiving either CPAP or HFNO.ConclusionsCPAP and HFNO delivered outside of the intensive care setting are viable treatment options for patients with hypoxaemic respiratory failure secondary to COVID-19 pneumonia, including those considered unsuitable for invasive mechanical ventilation. This provides an opportunity to safeguard intensive care capacity for COVID-19 patients requiring invasive mechanical ventilation.

A system dynamics approach to COVID-19 pandemic control: a case study of Iran

PurposeThe purpose of this paper is to develop a system dynamics approach based on Susceptible, Exposed, Infected, Recovered (SEIR) model to investigate the coronavirus pandemic and the impact of therapeutic and preventive interventions on epidemic disaster.Design/methodology/approachTo model the behavior of COVID-19 disease, a system dynamics model is developed in this paper based on SEIR model. In the proposed model, the impact of people's behavior, contact reduction, isolation of the sick people as well as public quarantine on the spread of diseases is analyzed. In this model, data collected by the Iran Ministry of Health have been used for modeling and verification of the results.FindingsThe results show that besides the intervening policies, early application of them is also of utmost priority and makes a significant difference in the result of the system. Also, if the number of patients with extreme conditions passes available hospital intensive care capacity, the death rate increases dramatically. Intervening policies play an important role in reducing the rate of infection, death and consequently control of pandemic. Also, results show that if proposed policies do not work before the violation of the hospital capacity, the best policy is to increase the hospital’s capacity by adding appropriate equipment.Research limitations/implicationsThe authors also had some limitations in the study including the lack of access to precise data regarding the epidemic of coronavirus, as well as accurate statistics of death rate and cases in the onset of the virus due to the lack of diagnostic kits in Iran. These parameters are still part of the problem and can negatively influence the effectiveness of intervening policies introduced in this paper.Originality/valueThe contribution of this paper includes the development of SEIR model by adding more policymaking details and considering the constraint of the hospital and public health capacity in the rate of coronavirus infection and death within a system dynamics modeling framework.

Economic impact of the COVID-19 pandemic in general and visceral surgery : Acomparison of performance and revenue data from two departments of hospitals with different levels of referral

HintergrundBereits während der ersten Welle der COVID-19-Pandemie wurden die deutschen Krankenhäuser dazu aufgefordert, ihre elektiven Operationskapazitäten einzuschränken, um eine Überlastung des Gesundheitswesens abzuwenden. Im März 2020 wurden mit dem COVID-19-Krankenhausentlastungsgesetz finanzielle Hilfen zum Ausgleich dieser Einschränkungen vereinbart. Die Auswirkungen dieser Maßnahmen wurden in dieser Studie regional untersucht.Material und MethodenEs wurden die Leistungsdaten und Erlöskennzahlen der Klinik für Allgemein- und Viszeralchirurgie des Universitätsklinikums Erlangen (UKER) und der Chirurgischen Abteilung des Kreiskrankenhauses St. Anna Höchstadt/Aisch (KKH) im Zeitraum 01.04. bis 30.06.2019 mit denen des Jahres 2020 verglichen.ErgebnisseEs zeigte sich eine deutliche Reduktion der Bettenauslastung und der Fallzahlen stationär behandelter Patienten. Letztere sanken um 20,06 % im UKER bzw. 60,76 % im KKH. Nichtonkologische elektive Operationen nahmen um 33,04 % (UKER) bzw. 60,87 % (KKH) ab. Die Anzahl der Notfalleingriffe blieb am UKER unverändert und verringerte sich am KKH um 51,58 %.Die Erlöse aus DRG („diagnosis-related groups“) sanken um 22,12 % (UKER) und 54 % (KKH). Nach Berücksichtigung der Ausgleichszahlungen und Einsparungen aus variablen Sachkosten verzeichnete das UKER einen Verlust von −3,87 %, das KKH erreichte hingegen einen positiven Erlöseffekt von 6,5 %.DiskussionDie nichtselektive Einschränkung des elektiven Operationsbetriebs beeinflusste die Patientenversorgung und die Erlöskennzahlen an beiden Standorten signifikant. In Bezug auf die Schaffung von Intensivkapazitäten erscheint diese ungezielte Maßnahme jedoch nicht effizient. Zudem führte die einheitliche Freihaltepauschale zu einer unausgeglichenen Verteilung der finanziellen Hilfen zwischen den untersuchten Kliniken.

"Prioritization and triage" in the context of cardiovascular diseases : Rational organization of safe care during and outside the corona pandemic

Seit Anfang des Jahres 2020 hat die durch die „coronavirus disease 2019“ (COVID-19) verursachte Pandemie weitreichende Folgen für die medizinische Versorgung in Deutschland und weltweit. Aktuell befindet sich Deutschland in der sog. 3. Pandemiewelle. Dazu kommen Mutanten des „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) mit erhöhter Virustransmission und schwerem Erkrankungsverlauf. Steigende SARS-CoV-2-Infektionszahlen münden in einer erhöhten Zahl schwerer COVID-19-Verläufe und einem erhöhten Bedarf intensivmedizinischer Behandlungen, die auf begrenzte strukturelle und personelle Ressourcen für COVID-19- und Non-COVID19-Patienten treffen. Dies – wie alle Situationen mit hoher Kapazitätsbelastung – macht eine Triagierung und Priorisierung von Erkrankten mit Zuteilung intensivmedizinischer Kapazitäten notwendig. Beide Strategien sind sinnvolle Organisationsformen und dürfen nicht mit einem Zusammenbruch der medizinischen Versorgung gleichgesetzt werden. Kardiovaskuläre Komorbiditäten und eine kardiale Mitbeteiligung bei COVID-19 sind für die Krankheitsschwere und den Krankheitsverlauf von besonderer Bedeutung. Neben der medizinischen Versorgung der Patienten mit pandemiebedingten akuten SARS-CoV-2-Infektionen müssen auch andere Patienten mit akuten, u. U. lebensbedrohlichen Erkrankungen unverändert mit hoher Qualität versorgt werden. Dieser Beitrag gibt eine aktuelle Übersicht über die vorgeschlagenen Restrukturierungsmaßnahmen in deutschen Krankenhäusern sowie damit einhergehenden Triagierungs- und Priorisierungsalgorithmen. Daneben ist es erforderlich, bestehende Behandlungsalgorithmen an die pandemische Lage zu adaptieren; dies wird aufgrund ihres besonderen Stellenwerts exemplarisch an kardiovaskulären Erkrankungen skizziert.

Impact of the SARS-CoV-2 pandemic on ophthalmic care in Germany.

BackgroundSurvey by the commission for cross-sectoral ophthalmology, as a joint commission of the German Ophthalmological Society (DOG) and the Professional Association of German Ophthalmologists (BVA) on the effects of the SARS-CoV‑2 pandemic on ophthalmological patient care in Germany.MethodsOnline-based survey.ResultsA total of 1190 questionnaires were (partly) answered. With respect to outpatient care and consultations from 15 March to 15 April 2020, a total of 69 (5.8%) participants indicated unlimited, 756 (63.5%) reduced and 330 (27.7%) emergency care only, independent of the type of institution. Outpatient surgery was restricted to emergency surgery in 68% of clinics, 42.0% of inpatient wards, 45.0% of surgical medical care centers and group practices and 33.0% of private practices. Inpatient procedures were limited to emergency care in 75.0% of inpatient wards and in 71.0% of clinics. With the exception of endophthalmitis (+8.2%), the number of urgent indications and emergencies declined: retinal detachment (−34.8%), perforating eyeball injuries (−7.3%), acute glaucoma (−17.8%), central retinal artery occlusion and anterior ischemic optic neuropathy (−31.0%), others (−30.9%), penetrating keratoplasty and amniotic membrane transplantation (−59.1%). Institutional or professional policy requirements (76.0%) and appointment cancellation by patients (84.0%) were the most common reasons for limitations in ophthalmic patient care.ConclusionThe initial phase of the pandemic was characterized by a massive reduction in non-urgent conservative and surgical treatment that affected all areas of ophthalmology. Due to intensive care capacities required for COVID-19 patients, inpatient treatment was largely restricted to emergencies. Treatment of ophthalmological patients, including ocular emergencies and urgent treatment, was maintained across all sectors with a (considerable) decrease in the number of cases even in these groups.

Responding to the COVID-19 pandemic: Development of a critical care nursing surge model to meet patient needs and maximise competencies

BackgroundThe current coronavirus disease 2019 (COVID-19) pandemic is creating unprecedented and unchartered demands on critical care units to meet patient needs and adapt the delivery of health services. Critical care nurses play a pivotal role in developing models of care that are effective, flexible, and safe. ObjectivesWe report on the accelerated development of a critical care nursing surge model responsive to escalating needs for intensive care capacity. MethodsWe conducted an exploratory prospective observational cohort study that included (i) a self-assessment and survey of learning needs of noncritical care nurses identified as candidate groups for redeployment in the intensive care unit and (ii) a pilot implementation of a team nursing model evaluated by individual questionnaires and the conduct of focus groups. We used descriptive statistics and qualitative content analysis to analyse the exploratory findings. ResultsWe surveyed 147 noncritical care nurses; 99 (67.3%) self-assessed at the lowest level of critical care competency, whereas 33 (24.3%) reported feeling able to help care for a critically ill patient under the direction of a critical care nurse. Identified learning needs included appropriate use of personal protective equipment in the intensive care unit (n = 123, 83.7%), use of specialised equipment (n = 103, 85.1%), basic mechanical ventilation, and vasoactive medication. We completed 11 team nursing pilot assignments with dyads of critical care and noncritical care nurses categorised in tiers of competencies. Nurses reported high levels of perceived support and provision of safe care; multiple recommendations were identified to improve the model of care delivery and communication. ConclusionsThe complexity, acuity, and unpredictability of the COVID-19 pandemic is placing new demands on critical care nurses to modify existing processes for care delivery while ensuring excellent outcomes and professional satisfaction. The study findings provide a road map to support nursing engagement in meeting patient needs.

COVID-19 health and social care access for autistic people: European policy review

BackgroundThe global COVID-19 pandemic has had an unprecedented impact on European health and social care systems, with demands on testing, hospital and intensive care capacity exceeding available resources in many...

Ethical heuristics for pandemic allocation of ventilators across hospitals.

In response to the COVID-19 pandemic philosophers and governments have proposed scarce resource allocation guidelines. Their purpose is to advise healthcare professionals on how to ethically allocate scarce medical resources. One challenging feature of the pandemic has been the large numbers of patients needing mechanical ventilatory support. Guidelines have paradigmatically focused on the question of what doctors should do if they have fewer ventilators than patients who need respiratory support: which patient should get the ventilator? There is, however, an important higher level allocation problem. Namely, how are we to ethically distribute newly obtained ventilators across hospitals: which hospital should get the ventilator(s)? In this paper, we identify a set of principles for allocating newly obtained ventilators across hospitals. We focus particularly on low and middle income countries, who frequently have limited pre-existing intensive care capacity, and have needed to source additional ventilators. We first provide some background. Second, we argue that the main population healthcare aim during the COVID-19 pandemic should be to save the most lives. Next, we assess a series of potential heuristics or principles that could be used to guide allocation: allocation to the most densely populated cities, random allocation, allocation based on the ratio of patients to ICU personnel, prioritisation in terms of intrahospital mortality, prioritisation of younger populations, and prioritisation in terms of population mortality. We conclude by providing a plausible ranking of the principles, while noting a number of epistemological challenges, in terms of how they best further the aim of increasing the probability of saving the most lives.

COVID-19 severe pneumonia: Prospective multicentre study on demands on intensive care capacities.

The aim of the study was to obtain data on demands on the intensive care capacities to treat COVID-19 patients, and to identify predictors for in-hospital mortality. The prospective observational multicentre study carried out from 1 March till 30 June 2020 included adult patients with confirmed SARS-CoV-2 infection with respiratory failure requiring ventilatory support or high-flow nasal oxygen therapy (HFNO). Seventy-four patients, 46 males and 28 females, median age 67.5 (Q1-Q3: 56-75) years, were included. Sixty-four patients (86.5%) had comorbidity. Sixty-six patients (89.2%) were mechanically ventilated, four of them received extracorporeal membrane oxygenation therapy. Eight patients (10.8%) were treated with non-invasive ventilation and HFNO only. The median of intensive care unit (ICU) stay was 22.5 days. Eighteen patients (24.3%) needed continuous renal replacement therapy. Thirty patients (40.5%) died. Age and acute kidney injury were identified as independent predictors of in-hospital death, and chronic kidney disease showed trend towards statistical significance for poor outcome. Sufficient number of intensive care beds, organ support equipment and well-trained staff is a decisive factor in managing the COVID-19 epidemic. The study focused on the needs of intensive care in the COVID-19 patients. Advanced age and acute kidney injury were identified as independent predictors for in-hospital mortality. When compared to clinical course and ICU management of patients with severe community-acquired pneumonia caused by other pathogens, we observed prolonged need for ventilatory support, high rate of progression to acute respiratory distress syndrome and significant mortality in studied population.

A national system for monitoring intensive care unit demand and capacity: the Critical Health Resources Information System (CHRIS)

A national system for monitoring intensive care unit demand and capacity: the Critical Health Resources Information System (CHRIS)

Public Preferences for Exit Strategies From COVID-19 Lockdown in Germany-A Discrete Choice Experiment.

Objectives: To decrease the rapid growth of SARS-CoV-2 in Germany, a stepped lockdown was conducted. Acceptance and compliance regarding entering and exiting lockdown measures are key for their success. The aim of the present study was to analyse the population's preferences for exiting lockdown measures. Methods: To evaluate population’s preferences and identify trade-offs between different exit strategies, a discrete choice experiment was conducted on 28–29 April (n = 1,020). Overall, six attributes and 16 choice sets (fractional-factorial design) without an opt-out were chosen. Conditional logit and latent class models were conducted. Results: Most attributes proved to be significant. Two attributes dominated all others: Avoiding a mandatory tracing app, and providing sufficient intensive care capacities. Preventing a high long-term unemployment rate and avoiding the isolation of persons aged 70+, were relevant, though utilities were comparatively lower. We identified subgroups (elderly persons and persons with school children) with different utilities, which indicates specific attributes affecting them dissimilarly. Conclusions: The population prefers cautious re-opening strategies and is at least sceptical about the adoption of severe protection measures. Government should balance interests between subgroups.

Modified PIRO (predisposition, insult, response, organ dysfunction) severity score as a predictor for mortality of children with pneumonia in Hasan Sadikin Hospital, Bandung, Indonesia.

BackgroundClinical manifestations for pneumonia vary from mild to severe. The PIRO model (predisposition, insult, response, organ dysfunction) was used as scoring system to determine severity of sepsis and pneumonia in adult patients. The PIRO model was modified for sorting the severity of pneumonia in children and predicting its risk of mortality.MethodsAn ambispective cohort study of pneumonia patients aged 1 month to ≤ 18 years admitted over the period from May to September 2020. Data were collected from history, physical examination, laboratory examination, and chest radiography. Based on bivariate analysis (p<0.05 and relative risk (RR) with 95% confidence interval), variables of each PIRO component that were significant for mortality were assigned a value of 1. The cut-off score for predictor of mortality was calculated using the receiver operating characteristics (ROC) curve and the scores were stratified into three degrees of risk based on interquartile range, score ≤Q1 was categorized as low risk; Q1-Q3 was categorized as moderate risk; and score >Q3 was categorized as high risk.ResultsOut of the 80 subjects enrolled, 6 months-5 years was the largest age group (56.3%). The observed mortality was 15/80 (18.8%). The modified PIRO severity score was compiled from significant variables of predisposition (malnutrition), insult (chest radiograph), response (hypoxemia, hypotension, CRP >0.5 mg/dL, PCT >0.5 ng/dL) and organ dysfunction, with range of score 0-7. Score >3 was categorized as a cut-off point score for predictor of mortality with AUC 0.919 (95% CI 0.836–0.968), sensitivity of 80%, and specificity of 84.62%. Subjects with score >3 have RR of 10.544 compared to those with score ≤3. The stratification of score level was low (≤2), moderate (3-4), and high (5-7). The mortality levels were 0%, 46.7%, and 53.3%, respectively.ConclusionsModified PIRO severity score can be used as a sorting tool and predictor of mortality risk in children with pneumonia. This score can also be used to select candidates for intensive care, especially in health facilities with limited intensive care capacity.