Intensive Care Unit Admission Status Research Articles

Enhanced recovery after surgery pathway leads to decreased length of stay for patients undergoing minimally invasive lung resection.

Enhanced recovery after surgery (ERAS) protocols in thoracic surgery have been demonstrated to impact length of stay (LOS), complication rates, and postoperative opioid use. However, ERAS protocols for minimally invasive lung resections have not been well described. Given most lung resections are now performed minimally invasively, there is a gap in the literature regarding the efficacy of ERAS protocols in this setting. In this study, we analyzed patient outcomes following implementation of an ERAS protocol for minimally invasive lung resections. Outcome data was retrospectively collected for 442 patients undergoing minimally invasive lung resections between January 1st, 2015 and October 26th, 2021. Patients were divided into either a pre-ERAS (n=193) or ERAS (n=249) group. Primary outcomes included LOS, postoperative complications, intensive care unit (ICU) admission status, 30-day hospital readmissions, and 30-day mortality. Secondary outcomes included common postoperative complications required for the Society for Thoracic Surgeons (STS) database. We observed an overall decrease in median LOS (4.0 vs. 3.0 days, P=0.030) and ICU admission status (15% vs. 7.6%, P=0.020) after implementation of our ERAS protocol. The difference in LOS was significantly lower for anatomic lung resections, but not non-anatomic resections. There was no difference in 30-day readmissions and a 0% mortality rate in both groups. Overall, there was a low complication rate that was similar between groups. The implementation of an ERAS protocol led to decreased LOS and decreased ICU admission in patients undergoing minimally invasive lung resection. Process standardization optimizes performance by providers by decreasing decision fatigue and improving decision making, which may contribute to the improved outcomes observed in this study.

Associated organs and system with COVID-19 death with information of organ support: a multicenter observational study

BackgroundThe organ dysfunction that is associated with death in COVID-19 patients has not been determined in multicenter epidemiologic studies. In this study, we evaluated the major association with death, concomitant organ dysfunction, and proportion of multiple organ failure in deaths in patients with COVID-19, along with information on organ support.MethodsWe performed an observational cohort study using the Japanese multicenter research of COVID-19 by assembling a real-world data (J-RECOVER) study database. This database consists of data on patients discharged between January 1 and September 31, 2020, with positive SARS-CoV-2 test results, regardless of intensive care unit admission status. These data were collected from the Diagnosis Procedure Combination and electronic medical records of 66 hospitals in Japan. The clinician identified and recorded the organ responsible for the death of COVID-19.ResultsDuring the research period, 4,700 patients with COVID-19 were discharged from 66 hospitals participating in the J-RECOVER study; of which, 272 patients (5.8%) from 47 institutions who died were included in this study. Respiratory system dysfunction (87.1%) was the leading association with death, followed by cardiovascular (4.8%), central nervous (2.9%), gastrointestinal (2.6%), and renal (1.1%) dysfunction. Most patients (96.7%) who died of COVID-19 had respiratory system damage, and about half (48.9%) had multi-organ damage. Of the patients whose main association with death was respiratory dysfunction, 120 (50.6%) received mechanical ventilation.ConclusionThis study showed that although respiratory dysfunction was the most common association with death in many cases, multi-organ dysfunction was associated with death due to COVID-19.

Clinical condition patterns of fully vaccinated brazilian patients of working age hospitalized due to severe Covid-19 according to ICU admission status

Objective: Discover patterns of clinical condition using data from patients of working age who were fully vaccinated against Covid-19, hospitalized due to the severe form of the disease, according to Intensive Care Unit (ICU) admission status in Brazil. Methods: This is a descriptive study with data extracted from the OpenDataSUS database using Association Rules Mining (ARM). Results: Information related to 3,470 individuals was described, of which 53% (n= 1,842) were male, 63% (n= 2,187) with comorbidities, 33% (n= 1,137) were admitted to the ICU and 23% (n= 796) died. ICU admission was associated with the use of invasive ventilatory support, male gender, presence of comorbidity, and death. For patients with no ICU admission, survival, absence of comorbidity, female gender, use of non-invasive ventilatory support and mild to moderate symptoms of the disease were found. Conclusion: These findings reinforce the need to administer booster doses of the Covid-19 vaccines, but also to strengthen policies to combat chronic noncommunicable diseases in Brazil.

Prognostik nütrisyonel indeks ve COVID-19 klinik seyri arasındaki ilişki: tek merkez deneyimi

Aim: It was aimed to investigate the relationship between the prognostic nutritional index (PNI) and the clinical course in COVID-19 because the nutritional status is important in defense against infection.
 Material and Method: 1579 patients who applied to the hospital inpatient clinic between 01/04/2020 and 30/11/2020 were included in the study. The PNI scores of the patients were calculated at the time of admission to the hospital. Comparisons were made between PNI scores of the patients and intensive care unit admission status, treatment results, length of hospital stay, and presence of pneumonia on thorax CT. Moreover, comparisons were made between PNI scores and C-reactive protein (CRP), neutrophil/ymphocyte ratio (NLR), CRP/albumin ratio. 
 Results: A total of 1579 patients (755 females and 824 males) were included in the study. The rate of admission to the ICU was significantly higher in males. The mortality rate of the study group was 9.4%. PNI scores were found to be significantly lower in patients who died and in patients admitted to the ICU. CRP and CRP/albumin ratio levels were significantly higher in patients with pneumonia on thorax CT, in patients admitted to the intensive care unit, and in patients who died. There were a significant negative correlation between PNI score and CRP/albumin ratio levels.
 Conclusion: PNI scores were found to be significantly lower in patients who needed admission to the intensive care unit and died due to severe COVID-19 than the others. In patients with a low PNI score, COVID-19 can be more severe and it may cause worse clinical outcomes.

Length of stay and trauma center finances: A disparity of payer source at a Level I trauma center.

In an effort to reduce costs, hospitals focus efforts on reducing length of stay (LOS) and often benchmark LOS against the geometric LOS (GMLOS) as predicted by the assigned diagnosis-related group (DRG) used by the Centers for Medicare and Medicaid Services. The objective of this cross-sectional study was to evaluate the impact of exceeding GMLOS on hospital profit/loss with respect to payer source. Contribution margin for each insured patient admitted to a Level I trauma center between July 1, 2016, and June 30, 2019, was determined. Age, ethnicity, race, DRG weight, DRG version, injury severity, intensive care unit admission status, mechanical ventilation, payer, exceeding GMLOS, and the interaction between payer and exceeding the GMLOS were regressed on contribution margin to determine significant predictors of positive contribution margin. Among 2,449 insured trauma patients, the distribution of payers was Medicaid (54.6%), Medicare (24.0%), and commercial (21.4%). Thirty-five percent (n = 867) of patient LOS exceeded GMLOS. Exceeding GMLOS by 10 or more days was significantly more likely for Medicaid and Medicare patients in stepwise fashion (commercial, 2.7%; Medicaid, 4.5%; Medicare, 6.0%; p = 0.030). Median contribution margin was positive for commercially insured patients ($16,913) and negative for Medicaid (-$8,979) and Medicare (-$2,145) patients. Adjusted multivariate modeling demonstrated that when exceeding GMLOS, Medicare and Medicaid cases were less likely than commercial payers to have a positive contribution margin (p < 0.001 and p < 0.001). Government-insured patients, despite having a payer source, are a financial burden to a trauma center. Excess LOS among government insured patients, but not the commercially insured, exacerbates financial loss. A shift toward a greater proportion of government insured patients may result in a significant fiscal liability for a trauma center. Economic and Value-Based Evaluation, Level III.

Maternal and infant hospitalization costs associated with hypertensive disorders of pregnancy in a California cohort*

Background The United States has higher health care costs than other developed nations. Hypertensive disorders of pregnancy are increasingly common, and longer hospital admissions and utilization of additional therapies are costly. Objective We sought to estimate maternal and neonatal hospital costs in a large cohort of pregnant women with and without hypertensive disorders of pregnancy. Study Design This was a retrospective cohort study of women in California with singleton, non-anomalous births with gestational ages between 23–42 weeks. Women were categorized into seven mutually exclusive groups: no hypertension, chronic hypertension (HTN), chronic HTN with superimposed preeclampsia, gestational HTN, mild preeclampsia, severe preeclampsia, and eclampsia. Hospitalization costs were estimated for women and neonates separately and included the cost for admission for delivery only. We used Chi squared and Kruskal–Wallis equality-of-populations rank tests for statistical analysis with a significance level of 0.05. Results In a California cohort of 1,918,482 women, 16,208 (0.8%) had chronic HTN, 5,912 (0.3%) had chronic HTN with superimposed preeclampsia, 39,558 (2.1%) had gestational HTN, 33,462 (1.7%) had mild preeclampsia, 17,184 (0.9%) had severe preeclampsia and 1252 (0.1%) had eclampsia. Median hospitalization costs and length-of-stays were statistically significantly different for women in each group (p<.001). Women with eclampsia had the highest median hospitalization costs ($25,437, IQR: $16,893–$37,261) and women without any hypertensive disorder of pregnancy had the lowest ($11,720, IQR: $8019–$17,530). Costs were significantly different between groups based on gestational age and mode of delivery, and with severe maternal morbidity and neonatal intensive care unit admission status (p<.001). Conclusions We found that hospitalization costs of hypertensive disorders of pregnancy were significantly higher than women without hypertension in pregnancy. These results highlight the economic burden of hypertensive disorders of pregnancy.

Incidence of and Risk Factors for Venous Thromboembolism Among Hospitalized Patients with Cancer and COVID-19: Report from the COVID-19 and Cancer Consortium (CCC19) Registry

Incidence of and Risk Factors for Venous Thromboembolism Among Hospitalized Patients with Cancer and COVID-19: Report from the COVID-19 and Cancer Consortium (CCC19) Registry

Hyperlipasemia and Potential Pancreatic Injury Patterns in COVID-19: A Marker of Severity or Innocent Bystander?

Hyperlipasemia and Potential Pancreatic Injury Patterns in COVID-19: A Marker of Severity or Innocent Bystander?

Vitamin C and thiamine are associated with lower mortality in sepsis.

The efficacy of vitamin C (VitC) and thiamine (THMN) in patients admitted to the intensive care unit (ICU) with sepsis is unclear. The purpose of this study was to evaluate the effect of VitC and THMN on mortality and lactate clearance in ICU patients. We hypothesized that survival and lactate clearance would be improved when treated with thiamine and/or VitC. The Philips eICU database version 2.0 was queried for patients admitted to the ICU in 2014 to 2015 for 48 hours or longer and patients with sepsis and an elevated lactate of 2.0 mmol/L or greater. Subjects were categorized according to the receipt of VitC, THMN, both, or neither. The primary outcome was in-hospital mortality. Secondary outcome was lactate clearance defined as lactate less than 2.0 mmol/L achieved after maximum lactate. Univariable comparisons included age, sex, race, Acute Physiology Score III, Acute Physiology and Chronic Health Evaluation (APACHE) IVa score, Sequential Organ Failure Assessment, surgical ICU admission status, intubation status, hospital region, liver disease, vasopressors, steroids, VitC and THMN orders. Kaplan-Meier curves, logistic regression, propensity score matching, and competing risks modeling were constructed. Of 146,687 patients from 186 hospitals, 7.7% (n = 11,330) were included. Overall mortality was 25.9% (n = 2,930). Evidence in favor of an association between VitC and/or THMN administration, and survival was found on log rank test (all p < 0.001). After controlling for confounding factors, VitC (adjusted odds ratio [AOR], 0.69 [0.50-0.95]) and THMN (AOR, 0.71 [0.55-0.93]) were independently associated with survival and THMN was associated with lactate clearance (AOR, 1.50 [1.22-1.96]). On competing risk model VitC (AOR, 0.675 [0.463-0.983]), THMN (AOR, 0.744 [0.569-0.974]), and VitC+THMN (AOR, 0.335 [0.13-0.865]) were associated with survival but not lactate clearance. For subgroup analysis of patients on vasopressors, VitC+THMN were associated with lactate clearance (AOR, 1.85 [1.05-3.24]) and survival (AOR, 0.223 [0.0678-0.735]). VitC+THMN is associated with increased survival in septic ICU patients. Randomized, multicenter trials are needed to better understand their effects on outcomes. Therapeutic Study, Level IV.

A Tertiary Care Center's Experience with Novel Molecular Meningitis/Encephalitis Diagnostics and Implementation with Antimicrobial Stewardship.

Novel molecular techniques, such as the Biofire FilmArray Meningitis/Encephalitis (ME) panel, are increasingly used to improve pathogen detection and time to detection (TtD). The Brooke Army Medical Center antibiotic stewardship program evaluated the impact of the ME panel on empiric antimicrobial usage. Negative ME panels were analyzed for days of therapy (DOT). The ME panel became available at Brooke Army Medical Center on January 1, 2016 and a retrospective chart review was performed on all hospitalized patients tested by ME panel through April 30, 2016. Demographic data, cerebral spinal fluid (CSF) leukocyte count, immunocompromised status, and intensive care unit admission status were collected. TtD by ME panel and CSF culture were compared and DOT for common antimicrobials were quantified. Positive ME panels were analyzed for same demographic data, diagnoses, and microbiologic workup including CSF cultures and send out polymerase chain reactions. Of the 77 ME panels performed during the study period, 54 (70%) were conducted on inpatients and included in the analysis. The majority of patients were males (n = 29, 54%) and the median age was 24 yr (interquartile range [IQR] 45; range 1 d to 83 yr). A total of eight (15%) patients were immunocompromised and 17 (31%) required intensive care unit level of care. The median TtD with the ME panel and CSF culture was 2.75 (IQR 2.16, 3.64) and 68.5 (IQR 63.87, 78.37) h, respectively. For negative ME panels, the overall median DOT for antimicrobials was 3 (IQR 1.5, 4.0) d, whereas the median DOT for individual agents was 2 (IQR 1.0, 4.0) d for vancomycin (n = 15), 1.5 (IQR 1.0, 2.25) d for ceftriaxone (n = 16), 3 (IQR 3.0, 4.0) d for ampicillin (n = 15), 3.5 (IQR 2.75, 4.0) d for gentamicin (n = 8), 3.5 (IQR 2.25, 4.0) d for cefotaxime (n = 6), and 5 (IQR 3.0, 5.5) d for acyclovir (n = 7); the median CSF leukocyte is of 2 cells/mm3 (IQR 1.0, 7.5). DOT excluded cases of positive ME panels: human herpes virus-6 (n = 2), herpes simplex virus-2 (n = 3), enterovirus (n = 1), and Streptococcus pneumoniae (n = 1). Of these, there were two discordance diagnoses between ME panel and convention microbiologic methods. S. pneumonia was detected on the ME panel and not on the CSF culture. One bone marrow transplant recipient had symptoms of encephalitis caused by human herpes virus-6 detected only by the ME panel, the send out human herpes virus-6 polymerase chain reaction was negative. The ME panel appears to improve diagnostic yield in our facility, and there is potential for improvement in decreasing empiric antimicrobial usage, particularly in patients with a negative ME panel and absence of CSF pleocytosis. This demonstrates the need for antibiotic stewardship program involvement to assist in implementation of rapid diagnostic tests through methods such as education, clinical guidelines, and prospective audit and feedback to improve meningitis and encephalitis management.