Intensive Care Unit Readmission Rate Research Articles

A retrospective chart analysis with 5-year follow-up of early care for geriatric hip fracture patients: why we should continue talking about hip fractures.

Timing of surgery remains a topic of debate for hip fracture treatment in the geriatric patient population. The quality indicator "early surgery" was implemented in 2014 at the Department of Trauma Surgery of the University Hospitals Leuven to enhance timely operative treatment. In this follow-up study, we aim to evaluate the performance of this quality indicator, the clinical outcomes, and room for improvement. The charts of 1190 patients surgically treated for an acute hip fracture were reviewed between June 2017 and May 2022 at the University Hospitals Leuven. Primary endpoints were adherence to early surgery, defined as surgery within the next calendar day, and the evaluation of the reasons for deviating from this protocol. Secondary endpoints were length of stay (LOS); intensive care unit (ICU) admission and length of ICU stay; mortality after 30days, 60days, 90days, and 6months; and 90-day readmission rate. Pearson's Chi-square test and Mann-Whitney U test were used for data analysis. One thousand eighty-four (91.1%) patients received early surgery versus 106 (8.9%) patients who received delayed surgery. The main reasons for surgical delay were the use of anticoagulants (33%), a general health condition not allowing safe surgery and/or existing comorbidities requiring workup prior to surgery (26.4%), and logistical reasons (17.9%). Patient delay and transfer from other hospitals were responsible for respectively 8.5% and 6.6% of delayed surgery. Early surgery resulted in a significantly shorter LOS and ICU stay (12 [8-25] vs. 18 [10-36] and 3 [2-6] vs. 7 [3-13] days, early vs. delayed surgery, respectively). No significant reduction was observed in ICU admission, mortality, and readmission rate. We have been able to maintain the early surgery hip fracture protocol in approximately 90% of the patients. Comorbidities and anticoagulant use were responsible for delayed surgery in the majority of the patients. Correct implementation of the existing protocol on anticoagulant use could lead to a one-third decrease in the number of delayed surgeries. Subsequently, since the LOS and ICU stay in the delayed surgery group were significantly longer, a further increase of early surgery will lower the current economic burden.

Successful Implementation of Enhanced Recovery After Surgery (ERAS) in Paediatric Cardiac Surgery in Australia

Fast-track or enhanced recovery after surgery (ERAS) is a care pathway for surgical patients based on a multidisciplinary team approach aimed at optimising recovery without increasing risk with protocols based on scientific evidence, which is monitored continuously to ensure compliance and improvement. These protocols have been shown to reduce the duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay (LOS) following paediatric cardiac surgery. We present the first structured implementation of ERAS in paediatric cardiac surgery in Australia. All patients enrolled in the ERAS pathway between October 2019 and July 2023 were identified. Demographic and perioperative data were collected retrospectively from hospital records for patients operated before June 2021 and prospectively from June 2021. A control group (non-ERAS) was identified using propensity matching from patients who underwent similar procedures and were not enrolled in the ERAS pathway (prior to October 2019). Patients were matched for age, weight, and comprehensive Aristotle score. Outcomes of interest were duration of postoperative mechanical ventilation, ICU LOS, readmission to the ICU, hospital LOS, cardiac reintervention rate, postoperative complication rate, and number of 30-day readmissions. Of 1,084 patients who underwent cardiac surgery during the study period (October 2019-July 2023), 121 patients (11.2%) followed the ERAS pathway. The median age at the time of surgery was 4.8 years (interquartile range [IQR] 2.8-8.8 years). The most common procedure was the closure of atrial septal defect (n=58, 47.9%). The median cardiopulmonary bypass and cross-clamp times were 40 min (IQR 28-53.5 minutes) and 24.5 min (IQR 13-34 minutes) respectively. The majority were extubated in the operating theatre (n=108, 89.3%). The median ICU and hospital LOS were 4.5 hrs (IQR 4.1-5.6 hours) and 4 days (IQR 4-5 days) respectively. None of the patients required readmission to the ICU within 24 hrs of discharge from the ICU. Three (3) patients (2.5%) required reintervention. When compared with the non-ERAS group, the duration of postoperative mechanical ventilation, ICU and hospital LOS were significantly lower in the ERAS group. There was no significant difference in the ICU readmission rate, reintervention rate, complication rate, and number of 30-day readmissions between both groups. ERAS after paediatric cardiac surgery is feasible and safe in select patients with low preoperative risk. This pathway reduces the duration of postoperative mechanical ventilation, ICU and hospital LOS without increasing risks, enabling the optimisation of resources.

Increased Neonatal Mortality and Increasing Rate of Cerebral Venous Sinus Thrombosis in Hospitalized Children: A Pediatric Health Information System Database Study

Introduction: Pediatric Cerebral Venous Sinus Thrombosis (CVST) poses risks of neurological sequelae and mortality, necessitating timely diagnosis and appropriate antithrombotic therapy. Limited sample sizes in previous studies have led to inconsistent treatment recommendations. To better understand pediatric CVST, we used the Pediatric Health Information System (PHIS) database to compare clinical features, treatment practices, and outcomes in neonates versus older children, and in different time periods, to analyze the influence of various parameters on healthcare outcomes. Methods: Deidentified, retrospective data of pediatric CVST was extracted from the large multi-center PHIS administrative database from January 1, 2011, to October 1, 2022. Diagnostic, imaging, procedure, and pharmaceutical billing codes were used to identify demographic information, clinical characteristics, management, and outcome. Multivariance analysis was performed on study parameters in neonates vs. older children (Table 1) and early (2011-2015) vs. late (2016-2022) study era (Table 2). Results: 6080 hospitalizations with CVST diagnosis (0.1% of all hospitalizations) were identified (61% male; median age 5 years; range 0-17 years). Median hospital stay was 8 days (IQR 4, 22), with 52% (N=3147) admitted to the intensive care unit (ICU). Overall mortality of all children was 4.2%. Neonates constituted 17.3% of the hospitalizations (N=1,054). Clinical features in neonates were less-often reported vs. older children more often had headache, hypertension, vomiting, papilledema and hemiparesis (p<0.001). Congenital heart disease/sepsis were common associated diagnoses in neonates vs. sinusitis/mastoiditis in older children (p<0.001). Neonates had a longer hospital stay (median 24 (IQR 11, 55), vs. 8 days (IQR 4, 17); p <0.001), but lower ICU admission (33.4% vs. 55.6%; p<0.001) and readmission rate (0% vs. 1.0%; p=0.002) when compared to older children. CT without contrast was used less often (33.4% vs. 55.1%; p < 0.001), and head ultrasound more often (76.3% vs. 8.0%; p < 0.001) for neonates vs. older children. Enoxaparin and unfractionated heparin (UFH) remained the primary treatments for CVST, with UFH utilized more often in neonates (71.6% vs. 59.2%; p<0.001). Direct oral anticoagulants (DOACs) were predominantly used in older children in limited numbers. Coma and hydrocephalus as complications were lower (0.7% vs. 5.6%, p<0.001 and 6.2% vs. 9.4%, p=0.001), and intracranial bleeding was (19.1% vs.7.0%, p<0.001) in neonates vs. older children. Neonates had increased mortality rate compared to older children (9.7% vs. 3.1%; p<0.001). The number of CVST admissions increased in the late (2016-2022) compared to the early study era (2011-2015) (0.11% vs. 0.08% of all admissions, p<0.001). Patient demographics, duration of hospital stay, ICU admission rates, clinical features, and imaging modalities remained similar in both groups. The use of bivalirudin, and DOACs was present in the late vs. none in the early era (p<0.001 except Dabigatran). Coma in the late (p<0.001) and brain infarct in the early study era (p<0.001) were more common complications. Both readmission rate (p=0.006) and hospital stay (p=0.006) were slightly higher in the late era. No statistically significant differences were found in mortality rate between the two eras (p= 0.226). Conclusion: Pediatric CVST is a serious disorder, with an overall mortality rate of 4.2% in our study. Neonates had distinct clinical features, associated diagnoses, and complications compared to older children. Predominantly UFH and rarely DOACs were administered in neonates. Neonates experienced longer hospital stay, and statistically significant higher mortality rate when compared to older children, consistent with prior studies. Newer anticoagulants were utilized increasingly in the late vs. early study era. Though readmission rate and hospital stay increased in the late era (not statistically significant), this did not translate into increased mortality. Increasing rate of hospitalizations in late compared to early study era is likely due to increasing medical complexity/technological advances in diagnosis/management of pediatric CVST. Future multi-center, prospective studies are needed to better address the increased neonatal mortality and improve overall care of pediatric CVST which is increasingly prevalent as seen in our study.

Utilisation of artificial intelligence to predict early readmission to the cardiac intensive care unit in critically ill patients

Abstract Background The need for cardiac intensive care unit (ICU) beds remains high in order to treat patients with severe cardiovascular diseases. Therefore, safe and timely discharge policies from the cardiac ICU to normal wards are crucial to meet the continuously increasing demand for cardiac ICU beds. ICU readmission after ICU discharge has been shown to increase mortality, hospital length of stay and costs. Artificial intelligence may provide a timely and accurate discharge decision support system for intensivists based on comprehensive, multi-dimensional ICU data. Purpose This is the first study to develop and validate a neuronal network, called Feedforward Neural Network (FNN), to safely discharge patients from the cardiac ICU and predict ICU readmission within 72 hours. Methods Adult patients who were admitted to the cardiac ICU due to a primary cardio-pulmonary admission diagnosis (such as acute myocardial infarction, cardiogenic shock or cardiac arrest) at a German tertiary care center between 2003 and 2021 were included. The dataset was split into a training and test dataset. The FNN was trained with 127 variables, including patient demographics, co-morbidities, medical diagnoses, disease acuity levels, laboratory values, vital parameters, ICU procedures and administered ICU medications. FNN was compared to the predictability of a classic logistic regression model and the Stability and Workload Index for Transfer (SWIFT) score, which is a clinical score to predict ICU readmission. Results 2,498 adult patients in the cardiac ICU met the inclusion criteria, out of which the FNN was trained in 1,998 (80.0%) patients and tested in 500 (20.0%) patients. The FNN had a 97.9% sensitivity, 86.9% specificity, 99.4% precision and 97.4% accuracy. FNN showed a better predictability of early ICU readmission than the logistic regression model and the SWIFT score: areas under the receiver operating characteristic (AUC ROC) curves were 90.78% vs. 71.34% vs. 71.13% (P <0.001) (Figure), respectively. Conclusions ICU transfer to the normal ward is considered to be a high-risk event and the vast amount of daily clinical, physiologic, laboratory and monitoring data may overwhelm critical care providers in making well informed decisions on patient discharge readiness. Artificial intelligence might be used as a sensitive, specific and accurate decision support system to help with patient discharge management and reduce ICU readmission rates.

Diversifying cardiac intensive care unit models: Successful example of an operating surgeon-led unit

ObjectiveThe intensivist-led cardiovascular intensive care unit model is the standard of care in cardiac surgery. This study examines whether a cardiovascular intensive care unit model that uses operating cardiac surgeons, cardiothoracic surgery residents, and advanced practice providers is associated with comparable outcomes. MethodsThis is a single-institution review of the first 400 cardiac surgery patients admitted to an operating surgeon-led cardiovascular intensive care unit from 2020 to 2022. Inclusion criteria are elective status and operations managed by both cardiovascular intensive care unit models (aortic operations, valve operations, coronary operations, septal myectomy). Patients from the surgeon-led cardiovascular intensive care unit were exact matched by operation type and 1:1 propensity score matched with controls from the traditional cardiovascular intensive care unit using a logistic regression model that included age, sex, preoperative mortality risk, incision type, and use of cardiopulmonary bypass and circulatory arrest. Primary outcome was total postoperative length of stay. Secondary outcomes included postoperative intensive care unit length of stay, 30-day mortality, 30-day Society of Thoracic Surgeons–defined morbidity (permanent stroke, renal failure, cardiac reoperation, prolonged intubation, deep sternal infection), packed red cell transfusions, and vasopressor use. Outcomes between the 2 groups were compared using chi-square, Fisher exact test, or 2-sample t test as appropriate. ResultsA total of 400 patients from the surgeon-led cardiovascular intensive care unit (mean age 61.2 ± 12.8 years, 131 female patients [33%], 346 patients [86.5%] with European System for Cardiac Operative Risk Evaluation II <2%) and their matched controls were included. The most common operations across both units were coronary artery bypass grafting (n = 318, 39.8%) and mitral valve repair or replacement (n = 238, 29.8%). Approximately half of the operations were performed via sternotomy (n = 462, 57.8%). There were 3 (0.2%) in-hospital deaths, and 47 patients (5.9%) had a 30-day complication. The total length of stay was significantly shorter for the surgeon-led cardiovascular intensive care unit patients (6.3 vs 7.0 days, P = .028), and intensive care unit length of stay trended in the same direction (2.5 vs 2.9 days, P = .16). Intensive care unit readmission rates, 30-day mortality, and 30-day morbidity were not significantly different between cardiovascular intensive care unit models. The surgeon-led cardiovascular intensive care unit was associated with fewer postoperative red blood cell transfusions in the cardiovascular intensive care unit (P = .002) and decreased vasopressor use (P = .001). ConclusionsIn its first 2 years, the surgeon-led cardiovascular intensive care unit demonstrated comparable outcomes to the traditional cardiovascular intensive care unit with significant improvements in total length of stay, postoperative transfusions in the cardiovascular intensive care unit, and vasopressor use. This early success exemplifies how an operating surgeon-led cardiovascular intensive care unit can provide similar outcomes to the standard-of-care model for patients undergoing elective cardiac surgery.

Continuation Versus De-escalation of Broad-Spectrum Antibiotic Therapy in Critically Ill COVID-19 Patients

BackgroundAntibiotic de-escalation (ADE) is a stewardship initiative that aims to reduce exposure to antimicrobials, thus limiting their unwanted effect, including antimicrobial resistance. Our study aims to describe the impact of ADE compared with the continuation of therapy on the outcome of critically ill coronavirus disease 2019 (COVID-19) patients.Material and MethodsA single-center retrospective study included critically ill COVID-19 adult patients admitted between January 1, 2019 and August 31, 2021, and started on broad-spectrum antibiotics. The primary outcome was intensive care unit (ICU) mortality. In addition, other clinical outcomes were evaluated, including ICU readmissions, length of stay, and superinfection.ResultsThe study included 73 patients with a mean age of 61.0 ± 19.4, and ADE was performed in 10 (13.6%) of these. In the ADE group, 8/10 (80%) cultures were positive. ICU mortality was not statistically different between ADE and continuation of therapy groups (60 vs. 41.3%, respectively, P = 0.317). Superinfection occurred in 4 (5.4%) patients. Hospital mortality, length of stay, and ICU readmission rates did not differ significantly between groups.ConclusionDe-escalation of broad-spectrum antibiotics in critically ill covid-19 patients was not associated with higher mortality. A larger cohort is needed to confirm these findings.

PSUN197 Rate of admission to the Intensive Care Unit in patients with Diabetic Ketoacidosis and its associated risk factors, a single centre experience.

Abstract Background Diabetic ketoacidosis (DKA) is one of the most common admission diagnoses to the intensive care unit (ICU). This study aims primarily to identify the rate of DKA-related ICU admission, and to assess the possible leading risk factors. Secondarily, to assess the rate of ICU readmission and mortality. Methods This retrospective observational study took place in King Abdulaziz University Hospital and collected data from January 2018 till December 2020. Patients aged 15 years and older with DKA Related-ICU admissions were included. Association between variables such as, demographics, precipitating factor, biochemical data, ICU stay details. History of readmission, arising complications within the study period were collected. Mortality cases were identified and the direct cause of death was investigated. Statistical analysiswas performed using the SPSS program version 25. Qualitative data were expressed as numbers and percentages, and quantitative data were expressed as mean and standard deviation. Linear regression analysis was used to adjust for the predictors and their association with the admission to the ICU. Result: ICU admissions were 28.4% of all DKA-related admissions (50 out of 176 patients), with a female predominance of 52%. Median length of ICU stay was 3 days. Medications nonadherence was the leading precipitating factor for ICU admission in 50% of the patients. Factors significantly associated with risk of ICU admission were on bivariate analysis: pH level of &amp;lt;7.0 (p =0.001), and Patients of &amp;gt;60 years as they had 4 times more risk of ICU admission compared to 15-20 years age group (P=0.04). Nine patients died, but none of them died primarily from DKA as the main cause of death was the DKA precipitating factor. Six patients were readmitted to the ICU (12%) during the study period, the mean duration between the two admissions was 19.74± 26.57 weeks. Conclusion Our findings highlight that nonadherence to medications is the most common precipitating factor to ICU-related DKA admission. Thus, educating patients and early dentification of patients at risk are crucial. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Effectiveness of a quality improvement strategy with implementation of a specific visual tool to promote ICU early mobilization

Early progressive mobilization is a safe strategy in the intensive care unit (ICU), however, it is still considered challenging by the inherent barriers and poor adherence to early mobilization protocol. The aim of this study was to evaluate the effectiveness of a quality improvement (QI) multifaceted strategy with implementation of a specific visual tool, the “mobility clock”, in reducing non-compliance with the institutional early mobilization (EM) protocol in adult ICUs. A single-center QI with a retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases. Patients from different periods presented similar baseline characteristics. After the QI strategy, a decline in “non-compliance” with the protocol was observed compared to the previous period (10.11% vs. 26.97%, p < 0.004). The proportion of patients walking was significantly higher (49.44% vs. 29.21%, p < 0.006) and the ICU readmission rate was lower in the “after” period (2.25% vs. 11.24%; p = 0.017). The multifaceted strategy specifically designed considering institutional barriers was effective to increase out of bed mobilization, to reduce the “non-compliance” rate with the protocol and to achieve a higher level of mobility in adult ICUs of a tertiary hospital.

S707 Comparison of Outcomes Between Upper and Lower GI Bleed Patients: A Post-Hoc Analysis of Retrospective Study

Introduction: Traditionally, lower gastrointestinal bleed (LGIB) patients tend to have a benign clinical course compared to those with upper gastrointestinal bleed (UGIB) patients leading to the over-utilization of resources in patients with UGIB. However, recent studies have reported similar clinical outcomes such as readmission and mortality rates, thereby challenging this view. Our study aimed to compare clinical outcomes between the two groups. Methods: This is a post-hoc analysis of a retrospective study on patients admitted with gastrointestinal bleed as their primary diagnosis to higher level of care from March, 2015 - March, 2021. Electronic medical records of patients above 18 years of age were reviewed. The patients were stratified into 2 groups: UGIB and LGIB. The outcomes analyzed included incidence of end organ damage (acute kidney injury and myocardial infarction), treatment modalities (conservative and/or endoscopic intervention), no. of patients requiring intensive care unit (ICU), hospital length of stay (LOS), 30-day mortality, and 90-day readmission rate. Pearson Chi-square and Mann Whitney U were applied to compare groups. p-value greater than 0.05 was considered significant. Results: Out of 207 eligible patients, 164 (79.2%) had UGIB, 34 (16.4%) LGIB, and remaining 9 (4.4%) had both. The latter were excluded from the analysis. Table illustrates baseline characteristics and outcomes. We did not observe any significant difference in the conservative treatment (transfusion requirement and antibiotics usage), endoscopic interventions, and time to scope between the two groups (p >0.05). Furthermore, there was no significant difference in no. of patients requiring ICU, hospital LOS, 30-day mortality, and 90-day readmission rates (due to UGIB and LGIB). Conclusion: Similar clinical outcomes were observed between the UGIB and LGIB patients in our study which is in line with the emerging data. Moreover, no difference was noted in the approach of treatment i.e., conservative and/or endoscopic. Our study also highlights that early endoscopic intervention and higher level of care may not be as necessary in all patients with UGIB. Table 1. - Illustrating the comparison of baseline characteristics, medical history, end organ damage (troponin leak and AKI), 30-day mortality, and 90-day readmission rates, between the with upper gastrointestinal bleed and lower gastrointestinal bleed Upper GI Bleed Lower GI Bleed p-value n (%) = 164 (79.2%) n, (%) = 34 (16.4%) Age, mean ± SD (median, IQR) 65.6 (55,77) 64.15 (51, 76.3) ns Gender Male 98 (47.3%) 25 (12.1%) Female 66 (31.9%) 9 (4.3%) ns Race ns Caucasian 104 (50.2%) 22 (10.6%) Black 23 (11.1%) 6 (2.9%) Hispanic 13 (6.3%) 2 (1.0%) Other including unavailable data 24 (11.6%) 4 (1.9%) History of HTN 92 (44.4%) 21 (10.1%) ns History of DM 39 (18.8%) 8 (3.9%) ns History of CAD 47 (22.7%) 14 (6.8%) ns History of NSTEMI/STEMI 13 (6.3%) 2 (1.0%) ns History of CKD 42 (20.3%) 8 (3.9%) ns History of Liver disease 35 (16.9%) 7 (3.4%) ns History of DVT/PE 16 (7.7%) 2 (1.0%) ns History of Smoking 74 (35.7%) 17 (8.2%) ns History of Alcohol use 76 (36.7%) 15 (7.2%) ns History of Illicit Drug use 7 (3.4%) 2 (1.0%) ns Personal history of GI tract cancer 14 (6.8%) 6 (2.9%) ns Family history of GI tract cancer 4 (1.9%) 8 (3.9%) 0.000 Use of NSAIDs 27 (16.8%) 3 (9.1%) ns Use of anticoagulants 49 (23.9%) 12 (5.9%) ns Use of antiplatelets 25 (27.6%) 14 (42.4%) ns Troponin leak 14 (6.8%) 3 (1.4%) ns AKI 48 (23.2%) 14 (6.8%) ns Antibiotics 32 (15.5%) 4 (1.9%) ns pRBC transfusion median (IQR) 3 (2,4) 3 (2,4.75) ns Endoscopic intervention 81 (39.1%) 13 (6.3)%) ns No. of patients requiring ICU 63 (30.4%) 8 (3.9%) ns Intubation during hospitalization 15 (7.2%) 0 (0.0%) ns Time to scope, mean ± SD (median, IQR) 1.35 ± 1.78 (1.0, 0.75-2.00) 1.72 ± 1.46 (1.0, 1-2) ns Alive at 30 days 142 (68.6%) 29 (14%) ns 90-day readmission due to GI Bleed 39 (18.8%) 7 (3.4%) ns NS – None significant; HTN – Hypertension; DM – Diabetes mellitus; CAD – coronary artery disease; HF – Heart Failure; AF – Atrial Fibrillation; CKD – Chronic Kidney Disease; DVT – Deep venous thrombosis; PE – Pulmonary embolism; NSAIDs – Non steroidal anti-inflammatory drugs; PPI – Proton Pump Inhibitors; AKI – Acute Kidney Injury; PRBC – Packed Red Blood Cells; ICU: Intensive Care Unit.

Evaluating the effect of age on postoperative and clinical outcomes in patients admitted to the intensive care unit after gastrointestinal cancer surgery

BackgroundThis study aimed to compare postoperative and clinical outcomes according to age and analyze the effect of age on mortality in patients admitted to the intensive care unit immediately after gastrointestinal cancer surgery. MethodsA total of 477 patients admitted to the intensive care unit after gastrointestinal cancer surgery between March 2018, and February 2020, were classified into 3 groups according to age: young (<65 years), older (65–79 years), and oldest (≥80 years) groups. We compared their disease severity scores as well as postoperative and clinical outcomes including mortality. ResultsThe young group comprised 167 (35.0%) patients, the older group 222 (46.5%) patients, and the oldest group 88 (18.4%) patients. There was a significant difference in the American Society of Anesthesiologists score, but not in the Acute Physiology and Chronic Health Evaluation II score, among the groups. The younger the age, the higher was the rate of vasopressor use; however, there were no significant differences in other postoperative and clinical outcomes, such as mechanical ventilation, length of hospital stay, length of intensive care unit stay, form of discharge, intensive care unit re-admission rate, in-hospital mortality, and in-30 days mortality. No significant differences in in-hospital survival, in-30 days survival, and overall survival were observed among the 3 groups. ConclusionThe comorbidities of patients increase with age; however, there was no significant difference in postoperative and clinical outcomes related to age. Thereby, the older population can successfully undergo major operations if adequate perioperative management is provided.

Immediate Extubation Versus Extubation Within Six Hours: Analysis of Clinical Outcomes in The Postoperative Period of Cardiac Surgery

The advances of the quality of anesthetics and of anesthetics techniques have facilitated the optimization of time for extubation in coronary heart disease graft. Aim: Comparison of clinical outcomes between patients extubated in the operating room and extubated patients within 6 hours after Intensive Care Unit (ICU) admission in patients undergoing cardiac surgery using extracorporeal circulation. Material and methods: A retrospective observational study of 194 patients submitted to cardiac surgery using extracorporeal circulation in one of the biggest tertiary hospitals in São Paulo. They were divided into two groups. In the first group, patient’s extubated in the operating room was composed of 95 patients. The second group of patients extubated within 6 hours of ICU admission from the intubated operating room, composed of 99 patients. We excluded 10 patients who were extubated after 6 hours of ICU admission. Results: Patients extubated in the operating room (median of 8 days, IQR 6 to 10) had shorter hospital stay time than patients extubated within 6 hours of ICU admission (median of 10 days, IQR 8 to 12.5), prevalence of similar delirium (2.0% x 2.1%), absence of pneumonia associated with mechanical ventilation (VAP) (0%), absence of non-caloric-protein readjustment (0%) and regarding safety, only one patient was reintubated for anesthetic recirculation in the group of extubated in the room and there was no difference in the rate of ICU readmission with the non-extubated group. Conclusion: In this sample of patients, we found that extubation in the room was safe. Patients extubated in the operating room immediately after cardiac surgery have a lower chance of evolving with prolonged hospitalization when compared to patients who are extubated within 6 hours of ICU admission.

Intensive care unit readmission in adult Egyptian patients undergoing living donor liver transplant: A single-centre retrospective cohort study.

BACKGROUNDPatients who undergo living donor liver transplantation (LDLT) may suffer complications that require intensive care unit (ICU) readmission.AIMTo identify the incidence, causes, and outcomes of ICU readmission after LDLT.METHODSA retrospective cohort study was conducted on patients who underwent LDLT. The collected data included patient demographics, preoperative characteristics, intraoperative details; postoperative stay, complications, causes of ICU readmission, and outcomes. Patients were divided into two groups according to ICU readmission after hospital discharge. Risk factors for ICU readmission were identified in univariate and multivariate analyses.RESULTSThe present study included 299 patients. Thirty-one (10.4%) patients were readmitted to the ICU after discharge. Patients who were readmitted to the ICU were older in age (53.0 ± 5.1 vs 49.4 ± 8.8, P = 0.001) and had a significantly higher percentage of women (29% vs 13.4%, P = 0.032), diabetics (41.9% vs 24.6%, P = 0.039), hypertensives (22.6% vs 6.3%, P = 0.006), and renal (6.5% vs 0%, P = 0.010) patients as well as a significantly longer initial ICU stay (6 vs 4 d, respectively, P < 0.001). Logistic regression analysis revealed that significant independent risk factors for ICU readmission included recipient age (OR = 1.048, 95%CI = 1.005-1.094, P = 0.030) and length of initial hospital stay (OR = 0.836, 95%CI = 0.789-0.885, P < 0.001).CONCLUSIONThe identification of high-risk patients (older age and shorter initial hospital stay) before ICU discharge may help provide optimal care and tailor follow-up to reduce the rate of ICU readmission.

Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study

BackgroundCritical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward. ObjectivesThe objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach–style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation. MethodsA new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions. ResultsThe service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care. ConclusionsCritical care outreach–style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.

Maxillofacial free flap surgery outcomes in critical care: a single-center investigation looking for clues to improvement

BackgroundMaxillofacial surgery for free flap reconstructions is associated with many complications due to technical complexity and comorbidity of patients. With a focus on critical care, the authors studied the impact of complications to highlight predictors of poor postoperative outcomes in order to implement optimization protocols.MethodsThis case-control study analyzed the relationship between perioperative variables and postoperative medical and surgical complications of patients who underwent head and neck surgery using fibular and forearm free flaps. The primary objective was the incidence of prolonged intensive care unit (ICU) length of stay (LOS). Secondary objectives were the incidence of ICU readmissions, postoperative infections, and 1-year mortality. A univariable logistic regression model was used. A study of mortality was performed with survival analysis. Regarding our primary objective, we performed a Benjamini-Hochberg procedure and a multivariable Poisson regression with defined variables of interest.ResultsThe data of 118 hospital stays were included. Prolonged ICU LOS was observed in 47% of cases and was associated with chronic obstructive pulmonary disease, pneumopathies, intraoperative blood transfusion, and surgical duration. Medical and surgical complications were associated with prolonged ICU LOS. After the Benjamini-Hochberg procedure, infectious complications, complications, major complications, total number of pneumopathies, and operative time remained significant. At least one complication was experienced by 71% of patients during the hospitalization, and 33% of patients suffered from major complications. Infectious complications were the most common (40% of patients) and were mainly caused by pneumonia (25% of patients); these complications were associated with low preoperative hemoglobin level, intraoperative blood transfusion, accumulation of reversible cardiovascular risk factors, chronic alcohol consumption, and duration of surgery. Pneumonia was specifically associated with chronic obstructive pulmonary disease. The ICU readmission rate was 10% and was associated with lower preoperative hemoglobin level, pneumopathies, surgical duration, and use of a fibular flap. The 1-year mortality was 12%, and the survival analysis showed no association with prolonged ICU LOS. Poisson regression showed that ICU LOS was prolonged by smoking history, lower preoperative hemoglobin level, intraoperative blood transfusion, major complication, and pneumopathies.ConclusionsPractices such as blood management and respiratory prehabilitation could be beneficial and should be evaluated as a part of global improvement strategies.

Intention to Stay in Specialist Trauma Nurses: Relationship With Role Conflict, Stress, and Organizational Support.

Specialist trauma nurses contribute to shortening hospital stay, lowering intensive care unit readmission rates, and improving treatment outcomes through early detection and management of health problems in trauma patients. However, Korean specialist trauma nurses have a higher turnover rate than other nurses due to negative factors like unclear job descriptions and inconsistent job activities. This study aimed to examine the levels of and relationships among role conflict, occupational stress, perceived organizational support, and intent to stay in Korean specialist trauma nurses. We enrolled 53 specialist trauma nurses from eight regional trauma centers in Korea. Data on role conflict, occupational stress, perceived organizational support, and intent to stay were collected using a structured questionnaire. Mann-Whitney U test, Kruskal-Wallis test, and Bonferroni post hoc tests were conducted to examine differences in intent to stay. Spearman's correlation coefficients were used to examine correlations between the key variables. High intent to stay was associated with periodic job training, job satisfaction, and perceived high workload. Role conflict was positively correlated with occupational stress, whereas both were negatively correlated with perceived organizational support. Intent to stay was negatively correlated with occupational stress and positively correlated with perceived organizational support. Effective improvement measures that lower occupational stress and increase perceived organizational support will help maintain the positions of specialist trauma nurses. These results highlight the need to specify the scope of practice and implement practical measures like career development programs that enhance professional nursing competencies to retain specialist trauma nurses.

PHENOBARBITAL VS BENZODIAZEPINES FOR ALCOHOL WITHDRAWAL MANAGEMENT IN MEDICAL ICU: PRELIMINARY RESULTS OF PRE-POST PROTOCOL STUDY

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Phenobarbital (PB) has been suggested as an alternative to benzodiazepines (BZD) for alcohol withdrawal (AW) management. Few studies have examined the efficacy of different PB regimens for the management of AW in the medical intensive care unit (ICU). METHODS: Retrospective, pre-post protocol, cohort study for patients with AW syndrome admitted to the medical ICU at Cleveland Clinic, Fairview Hospital, during the period from January 2019 through April 2021. Historically a symptom-triggered BZD based protocol utilizing CIWA-Ar has been employed. In September 2020, a PB-based protocol was implemented for AW management. The protocol included PB 260 mg intravenous (IV) followed by 130 mg IV repeated doses every 15 - 30 minutes as needed up to a total of 15 mg/kg (ideal body weight) to maintain CIWA-Ar score below 10. We included adult patients who were admitted to medical ICU primarily for AW management. We excluded patients intubated before ICU admission or the presence of a serious medical or surgical diagnosis that would have otherwise dictated admission to the ICU. The primary outcome is ICU length of stay (LOS). Secondary outcomes include hospital LOS, intubation rate, the number of adjunctive agents, medication side effects, requirement for sitter, restraining, ICU readmission and mortality rate. RESULTS: A total of 270 patients were screened, of which only 62 patients with AW were enrolled, 15 in the PB arm and 47 in the BZD arm. Overall, 32% of all patients presented as uncomplicated AW, 42% as delirium tremens, and 13% as AW seizure. No significant differences in basic characteristics between arms were observed. Compared to BZD arm, patients who received PB had significant shorter ICU LOS (median [IQR], 28 hours [24 – 37] vs 59 hours [34 – 115]; P=<.001) and hospital LOS (median [IQR] 4 days [3 – 5] vs 6 days [4 – 10]; P=.006). PB arm required less number of adjunctive agents to control AW (1 [0 – 1] vs 3 [2 – 4]; p=<.001) including less utilization of dexmedetomidine (1 [7%] vs 22 [47%]; p=<.001). None of the patients in the PB arm required restraint use (0 vs 27 [57%]; p=<.001). No significant difference between arms with regards to medication side effects, sitter requirement, ICU readmission, intubation rate, and mortality rate. CONCLUSIONS: The initial findings from our study are suggesting that our proposed PB-AW management protocol is associated with shorter ICU and hospital LOS. It may be considered as an effective and safe alternative to BZD. CLINICAL IMPLICATIONS: Our results will help in evolving AW management guidelines in ICU. DISCLOSURES: No relevant relationships by Saira Afzal, source=Web Response No relevant relationships by BASSEL AKBIK, source=Web Response No relevant relationships by Dina alayan, source=Web Response No relevant relationships by Sura Alqaisi, source=Web Response No relevant relationships by Mahmoud Alwakeel, source=Web Response No relevant relationships by Ellen Immler, source=Web Response No relevant relationships by Talha Saleem, source=Web Response No relevant relationships by Xiaofeng Wang, source=Web Response

Effect of rapid methicillin-resistant Staphylococcus aureus nasal polymerase chain reaction screening on vancomycin use in the intensive care unit.

PurposeTo determine the impact of a pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) screen on vancomycin duration in critically ill patients with suspected pneumonia.MethodsThis was a retrospective, quasi-experimental study at a 613-bed academic medical center with 67 intensive care beds. Adult patients admitted to the intensive care unit (ICU) between 2017 and 2019 for 24 hours or longer and empirically started on intravenous vancomycin for pneumonia were included. The primary intervention was the implementation of a MRSA nasal PCR screen protocol. The primary outcome was duration of empiric vancomycin therapy. Secondary outcomes included the rate of acute kidney injury (AKI), the number of vancomycin levels obtained, the rate of resumption of vancomycin for treatment of pneumonia, ICU length of stay, hospital length of stay, the rate of ICU readmission, and the rate of in-hospital mortality.ResultsA total of 418 patients were included in the final analysis. The median vancomycin duration was 2.59 days in the preprotocol group and 1.44 days in the postprotocol group, a reduction of approximately 1.00 day (P < 0.01). There were significantly fewer vancomycin levels measured in the postprotocol group than in the preprotocol group. Secondary outcomes were similar between the 2 groups, except that there was a lower rate of AKI and fewer vancomycin levels obtained in the postprotocol group (despite implementation of area under the curve–based vancomycin dosing) as compared to the preprotocol group.ConclusionThe implementation of a pharmacist-driven MRSA nasal PCR screen was associated with a decrease in vancomycin duration and the number of vancomycin levels obtained in critically ill patients with suspected pneumonia.

Respiratory events after intensive care unit discharge in trauma patients: Epidemiology, outcomes, and risk factors.

Respiratory complications are associated with significant morbidity and mortality in trauma patients. The care transition from the intensive care unit (ICU) to the acute care ward is a vulnerable time for injured patients. There is a lack of knowledge about the epidemiology of respiratory events and their outcomes during this transition. Retrospective cohort study in a single Level I trauma center of injured patients 18 years and older initially admitted to the ICU from 2015 to 2019 who survived initial transfer to the acute care ward. The primary outcome was occurrence of a respiratory event, defined as escalation in oxygen therapy beyond nasal cannula or facemask for three or more consecutive hours. Secondary outcomes included unplanned intubation for a primary pulmonary cause, adjudicated via manual chart review, as well as in-hospital mortality and length of stay. Multivariable logistic regression was used to examine patient characteristics associated with posttransfer respiratory events. There were 6,561 patients that met the inclusion criteria with a mean age of 52.3 years and median Injury Severity Score of 18 (interquartile range, 13-26). Two hundred and sixty-two patients (4.0%) experienced a respiratory event. Respiratory events occurred early after transfer (median, 2 days, interquartile range, 1-5 days), and were associated with high mortality (16% vs. 1.8%, p < 0.001), and ICU readmission rates (52.6% vs. 4.7%, p < 0.001). Increasing age, male sex, severe chest injury, and comorbidities, including preexisting alcohol use disorder, congestive heart failure, and chronic obstructive pulmonary disease, were associated with increased odds of a respiratory event. Fifty-eight patients experienced an unplanned intubation for a primary pulmonary cause, which was associated with an in-hospital mortality of 39.7%. Respiratory events after transfer to the acute care ward occur close to the time of transfer and are associated with high mortality. Interventions targeted at this critical time are warranted to improve patient outcomes. Prognostic and Epidemiological study, level III.

Nutritional risk screening in noninvasively mechanically ventilated critically ill adult patients: A feasibility trial

BackgroundMalnutrition rates for critically ill patients being admitted to the intensive care unit (ICU) are reported to range from 38% to 78%. Malnutrition in the ICU is associated with increased mortality, morbidity, length of hospital admission, and ICU readmission rates. The high volume of ICU admissions means that efficient screening processes to identify patients at nutritional or malnutrition risk are imperative to appropriately prioritise nutrition intervention. As the proportion of noninvasively mechanically ventilated patients in the ICU increases, the feasibility of using nutrition risk screening tools in this population needs to be established. ObjectivesThe aim of this study was to compare the feasibility of using the Malnutrition Universal Screening Tool (MUST) with the modified NUtriTion Risk In the Critically ill (mNUTRIC) score for identifying patients at nutritional or malnutrition risk in this population. MethodsA single-centre, prospective, descriptive, feasibility study was conducted. The MUST and mNUTRIC tool were completed within 24 h of ICU admission in a convenience sample of noninvasively mechanically ventilated adult patients (≥18 years) by a trained allied health assistant. The number (n) of eligible patients screened, time to complete screening (minutes), and barriers to completion were documented. Data are presented as mean (standard deviation), and the independent samples t-test was used for comparisons between tools. ResultsTwenty patients were included (60% men; aged 65.3 [13.9] years). Screening using the MUST took a significantly shorter time to complete than screening using the mNUTRIC tool (8.1 [2.8] vs 22.1 [5.6] minutes; p = 0.001). Barriers to completion included obtaining accurate weight history for the MUST and time taken for collection of information and overall training requirements to perform mNUTRIC. ConclusionsThe MUST took less time and had fewer barriers to completion than mNUTRIC. The MUST may be the more feasible nutrition risk screening tool for use in noninvasively mechanically ventilated critically ill adults.

Outcomes of non-COVID-19 critically ill patients during the COVID-19 pandemic : Aretrospective propensity score-matched analysis.

BackgroundCoronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed.MethodsThe objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching.ResultsA total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2–6) compared to 2020: 4 days (IQR 2–7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344.ConclusionIn this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.