Intensive Care Unit Utilization Research Articles

387 ICU Utilization in Elective Endovascular Treatment of Unruptured Intracranial Aneurysms

INTRODUCTION: Evidence suggests routine post-operative intensive care unit (ICU) admission in high-risk neurosurgical procedures, including endovascular treatment of unruptured intracranial aneurysms (UIA), may be unnecessary, though current practice patterns are undescribed. We sought to evaluate trends in ICU utilization in patients undergoing elective endovascular repair of UIA in the United States. METHODS: This is a retrospective cohort study utilizing commercial claims from a nationwide longitudinal database of multiple payors in the U.S. (MarketScan) to evaluate ICU use in patients undergoing elective, endovascular repair of UIA between 2005 and 2019. Our initial cohort was defined using diagnosis codes and CPT procedural codes. Patients with ruptured aneurysms were excluded, and the remaining unruptured patients were separated by ICU revenue codes to identify those who were likely admitted to the ICU post-operatively. A combination of diagnosis codes and procedural codes were utilized to evaluate demographics, pre-operative comorbidities, post-procedural complications, and discharge status. Cost analysis was also performed. RESULTS: Of 6218 patients who underwent elective endovascular treatment of UIA, 78.6% (4890) of patients were placed in the ICU post-operatively, and this percentage remained stable over the study period. No differences in age, sex, comorbidity scores, or smoking history were found between patients admitted to the ICU versus those admitted to the floor. ICU utilization was more common in urban locations (p < 0.001). The average total payment was higher in patients admitted to the ICU post-operatively ($46,429 versus $40,552, p < 0.0001). CONCLUSIONS: Almost 80% of patients undergoing elective endovascular repair of UIA are admitted to the ICU postoperatively, despite multiple studies suggesting this practice is unnecessary. Costs are significantly higher in patients utilizing the ICU. Reducing routine ICU use in this subgroup of patients may reduce costs and resource utilization in a safe manner.

412 A Protocol for Reducing Intensive Care Utilization After Craniotomy: A Three-Year Assessment

INTRODUCTION: Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the “Non-Intensive CarE” (NICE) protocol to identify craniotomy patients that did not require postoperative ICU care. METHODS: Our institution’s electronic medical record (EMR) was queried to identify craniotomies prior to protocol deployment (May 2014-May 2018), and after deployment (May 2018-December 2021). Patients are considered for the protocol if they are having an elective craniotomy for select procedures (e.g. microvascular decompressions, extra-axial tumor resection), are under age of 65, have no history of coagulopathy, and have no other medical contraindications. Reason for readmission or reoperation among NICE protocol patients was collected via chart review. The primary endpoints were average POLS and ICU utilization; secondary endpoints included readmission, reoperation, and postoperative complications rates. Endpoints were compared among pre- and post-protocol cohorts. RESULTS: 4,837 craniotomies were performed from May 2014-December 2021 (2,302 pre-protocol, 2,535 post-protocol). 21% percent of post-protocol craniotomies were enrolled in the NICE protocol. After protocol deployment, overall POLS decreased from 4.0 to 3.5 days (p = 0.0031), which was driven by deceased POLS among protocol patients (average 2.4 days).ICU utilization decreased from 57% of patients to 42% (p < 0.0001), generating ∼$760,000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within thirty days; none could have been prevented through ICU stay. CONCLUSIONS: The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

The impact of COPD on the private healthcare system in Brazil: an economic analysis

Objective: To assess healthcare resource utilization and hospitalization costs of patients with chronic obstructive pulmonary disease (COPD) exacerbations in the Brazilian private healthcare system. Methods: A retrospective cohort study, considering data from an administrative database of a private company (Orizon). Patients aged ≥40 years old and with at least one COPD-related claim identified by the ICD-10 code (J40 to J44) at any time during the eligibility period (January/2010 to December/2013) were included in the analysis. Follow-up was performed until December/2014, death or inactivation of a health plan. Sociodemographic characteristics, number of emergency visits, hospital admissions (number and length of stay), length of hospital stay in an intensive care unit (ICU), number of severe COPD exacerbations, therapeutic approach, and hospitalization costs were assessed. Results: The analysis included 8,254 COPD patients. Emergency visits, hospital admission, and exacerbation rates were 0.4, 0.2, and 0.1 per person-year, respectively. The mean length of hospital stays and the length of stay of patients requiring or not ICU stay were 16.6 (SD = 77.0), 8.7 (SD = 36.9), and 27.6 (SD = 109.7), respectively. Mean costs associated to emergency department visits and hospitalizations were 258.2 BRL (SD = 383.1) and 38,165.4 BRL (SD = 124,683.5), respectively. Hospitalizations costs without ICU stay were 11,810.1 BRL (SD = 31,144.1) and 74,585.3 BRL (SD = 182,808.1) for those with ICU utilization. Conclusion: Costs for COPD management during disease exacerbation are very high and may reach almost 75 thousand BRL per hospitalization. The prevention of COPD exacerbations and better disease control may reduce the economic burden on the private healthcare system in Brazil.

Bed utilization pattern of intensive care units affiliated to Ministry of Health: a national study in Egypt prior to the COVID-19 pandemic

BACKGROUND: This study aims to calculate the following bed utilization of intensive care Units (ICU) at the national and regional levels. METHODS: A descriptive retrospective record-based study was done in all ICUs affiliated to Ministry of Health and Population (MOHP). RESULTS: ICU admission rate ranged from 0.09% to 0.41% with 0.19%. BOR ranged from 10% to 72% with 60%. The ALS (Days) ranged from 1.92 days to 5.41 days with 3.61 days. The average ABTI per year ranged from 1.42 days to 25.04 days with 2.46 days. The average ABTR ranged from 13.14 to 101.02 with 60.14. CONCLUSIONS: Utilization of ICUs affiliated to MOHP is not optimal at the national level and there is a room for improvement.

Evaluation of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage

Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI). To derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage. This retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022. Assigned ESI level. Rate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage. A total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]). In this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.

Evolving Management of Acute Mastoiditis: Analysis of the Pediatric Health Information System Database

The optimal management of acute mastoiditis remains controversial. Most existing studies are retrospective single-institutional experiences with small cohorts. Our objectives were to analyze the treatment of acute mastoiditis by pediatric centers across the United States and changes in management over time. Retrospective analysis. Administrative database study using Pediatric Health Information System. Patients ≤18 years of age who were admitted with a principal diagnosis of acute mastoiditis from January 1, 2010 to December 31, 2019 were included. Trends were assessed by Cochran-Armitage Trend Test. χ2 and Wilcoxon rank sum tests were used to compare outcomes between the surgical and nonsurgical groups. A total of 2170 patients met the inclusion criteria, with 1248 (57.5%) requiring surgical management. The rate of surgical procedures decreased significantly over time. The rate of myringotomy decreased from 64% in 2010 to 47% in 2019 (p < .001), and mastoidectomy decreased from 22% in 2010 to 10% in 2019 (p < .001). On admission, 29% of the cohort presented with mastoiditis-related complications. Patients treated surgically were younger (p < .001), more likely to present with complications (37.5% vs 17.5%, p < .001), required longer lengthof stay (3.7vs 2.3 days, p < .001), and had higher intensive care unit utilization (8.6% vs 2.2%, p < .001). However, the rate of 30-day readmission, emergency department return, and in-hospital mortality were all similar. Acute mastoiditis has been successfully treated with declining rates of a surgery over time. Younger patients who present with complications are more likely to be managed surgically, and the overall outcomes remain excellent.

Institutional outcomes of blunt liver and splenic injury in the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium era.

The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium practice management guideline was created to standardize management of blunt liver or spleen injury across pediatric trauma centers. We describe our outcomes since guideline adoption at our institution and hypothesize that blunt liver or spleen injury may be managed more expeditiously than currently reported without compromising safety. A retrospective cohort study was conducted on patients younger than 18 years presenting with blunt liver and/or splenic injuries from March 2016 to March 2021 at one participating center. A total of 199 patients were included. There were no clinically relevant differences for age, body mass index, or sex among the cohort. Isolated splenic injuries (n = 91 [46%]) and motor vehicle collisions (n = 82 [41%]) were the most common injury and mechanism, respectively. The overall median length of stay (LOS) was 1.2 days (interquartile range, 0.45-3.3 days). Intensive care unit utilization was 23% (n = 46). There was no statistically significant difference in median LOS among patients with isolated solid organ injuries, regardless of injury grade. There were no readmissions associated with non-operative management. The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium guideline fosters high rates of nonoperative management with low intensive care unit utilization and LOS while demonstrating safety in implementation, irrespective of injury grade. Therapeutic/Care Management; Level IV.

A Protocol for Reducing Intensive Care Utilization After Craniotomy: A 3-Year Assessment.

Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the "Non-Intensive CarE" (NICE) protocol to identify craniotomy patients who did not require postoperative ICU care. To determine the longitudinal impact of the NICE protocol on postoperative length of stay (LOS), ICU utilization, readmissions, and complications. In this retrospective cohort study, our institution's electronic medical record was queried to identify craniotomies before protocol deployment (May 2014-May 2018) and after deployment (May 2018-December 2021). The primary end points were average postoperative LOS and ICU utilization; secondary end points included readmissions, reoperation, and postoperative complications rate. End points were compared between pre- and postintervention cohorts. Four thousand eight hundred thirty-seven craniotomies were performed from May 2014 to December 2021 (2302 preprotocol and 2535 postprotocol). Twenty-one percent of postprotocol craniotomies were enrolled in the NICE protocol. After protocol deployment, the overall postoperative LOS decreased from 4.0 to 3.5 days ( P = .0031), which was driven by deceased postoperative LOS among protocol patients (average 2.4 days). ICU utilization decreased from 57% of patients to 42% ( P < .0001), generating ∼$760 000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within 30 days; none could have been prevented through ICU stay. The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

Intensive care utilisation after elective surgery in Australia and New Zealand: getting the balance right.

Of the total intensive care unit (ICU) admissions in Australia and New Zealand, 36.6% occur following an elective surgical procedure. How best to use ICU services in this setting is not clear, despite this being an expensive and resource-intensive method of care delivery. The literature relating to this area has not demonstrated a clear association between improved outcomes and routine ICU utilisation. It has, however, demonstrated that methods of care delivery in this setting vary at the local, national and international level. There is now an increased interest in how we can offer safe, efficient care to patients who need ICU-level support after elective surgery, as well as where and when that care can be offered. We had previously performed a literature review relating to ICU utilisation in the elective surgical post-operative setting. This perspective piece arises from this literature review as well as extensive clinical experience from the authors. We discuss the need for a move towards an evidence-based indication for ICU admission and how this may be achieved. We then move on to the various alternative models of care that could be offered, briefly discussing their positives and potential drawbacks. We finish by outlining the research priorities and how these might be implemented in clinical practice. Getting the balance right between ICU admission and higher acuity ward-level care for post-operative elective surgical patients is difficult. However, this is an important challenge that we as a healthcare community must be working to answer.

Assessing the impact of palliative care admission of end-of-life cancer adults.

There is evidence that early admission to the palliative care (PC) program in adult cancer patients improves symptoms management, reduces unplanned hospital admissions, minimizes aggressive cancer treatments, and enables patients to make decisions about their end-of-life (EOL) care. This retrospective cohort study aimed to determine whether late admission to a PC program is associated with aggressive treatment at the EOL in adult patients with oncological diseases from their admission until death. The study evaluated the aggressiveness in EOL management in patients with advanced stage oncological diseases who died between 2017 and 2019. The study population was divided into two groups based on the time of admission to the PC program. Aggressiveness at the EOL was measured using five criteria: treatment, hospital admission and duration, emergency department care, and/or intensive care unit utilization. The study found a significant difference in the rate of aggressive EOL treatments between late admission to PC care and early admission [adjusted EOL 79.6% versus 70.4%; relative risk (RR): 1.98, 90% CI: 1.08-3.59, p: 0.061]; In the analysis of secondary variables, a significant association was observed between early admission to PC and the suspension of active treatments at the EOL, leading to a decrease in aggressiveness (77% versus 55.8%; RR: 1.38, 95% CI: 1.14-1.67, p: 0.004). Our findings suggest that early referral to PC services is associated with less aggressive treatment at the EOL, including suspension of active treatments.

Transfusion-reducing techniques decrease perioperative morbidity of Cesarean hysterectomy for placenta accreta spectrum

Placenta accreta spectrum (PAS) is associated with high rates of hemorrhage and serious morbidity. Transfusion-reducing techniques have been used successfully in cardiac surgery to decrease blood loss and blood utilization. The purpose of this study is to evaluate the impact of these techniques on perioperative morbidity for women undergoing Cesarean hysterectomy for PAS. This cohort study was performed at a tertiary center between 2011-2021 and compared women with prenatally-diagnosed PAS undergoing Cesarean hysterectomy with transfusion-reducing techniques to those having the procedure without. Emergent cases and those with incidentally encountered PAS at delivery were excluded. The treatment group protocol involved iron supplementation, tranexamic acid (TXA), the LigaSure vessel sealing system, intraoperative ultrasound-guided placental mapping, and intraoperative blood salvage (Cell Saver). Outcomes were estimated blood loss (EBL), rates of overall and large-volume transfusion (≥4 units packed red blood cells [pRBC]), and intensive care unit (ICU) utilization. Statistical analysis included chi-square, t-test, or Mann-Whitney U test, with p< 0.05 designated for statistical significance. Of the 55 patients studied, 35 were in the transfusing-reducing group and 20 were in the control group. Groups were similar in terms of age, body mass index, parity, and uterine surgical history; the transfusion-reducing group had higher use of iron, TXA, LigaSure, and placental mapping (Table 1). There was decreased EBL (median 1500 (750 – 2000mL) vs. 2750 (1850 – 3500mL), p < .001), overall transfusion (n=15 (43%) vs. n=17 (85%), p=.004), ≥4 units pRBC transfusion (n=5 (14%) vs. n=12 (60%), p< .001) and ICU admission (n=9 (26%) vs. n=18 (90%), p< .001) in the treatment group (Table 2). Surgical blood loss and blood transfusion can be safely reduced in patients undergoing scheduled Cesarean hysterectomy for suspected PAS by using the principles of transfusion-reducing surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Sociodemographic Factors Associated with Do-Not-Resuscitate Order Utilization in the Surgical Intensive Care Unit: An Observational Study.

The use of a do-not-resuscitate (DNR) order is a powerful tool in outlining end-of-life care. This study explores sociodemographic factors associated with selection of a DNR order and assigning a healthcare proxy in the Surgical Intensive Care Unit (SICU). A retrospective chart review of 312 patients who expired in the SICU over a 7-year period was conducted. We analyzed the association of sociodemographic factors to selection of a DNR order and assignment of a healthcare proxy. Year of admission, age, religion, and proxy were independently associated with selection of DNR. In particular, the relative chance of a DNR selection in 2019 compared to 2012 was 3.538 (95% CL = 2.001-6.255, P < .01). There are significant sociodemographic factors that influence DNR utilization, highlighting the need to consider the social and religious backgrounds when engaging patients and their families in end-of-life care. Future studies will need to be conducted on whether these sociodemographic factors influence surviving patients as this study's findings can only be applied to those who have expired.

CLINICAL CHARACTERISTICS AND MORTALITY IN ADULTS 85 YEARS AND OLDER HOSPITALIZED WITH SARS-COV-2

Abstract Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) places older adults at increased risk of hospitalization and mortality due to coronavirus disease 2019 (COVID-19). To date, research and regulatory data describe adults 65 years and older, with few reporting on characteristics specific to older adults 85 and older (“oldest-old”). A consecutive 12-month case series including 1,510 oldest-old patients hospitalized with SARS-CoV-2 is presented to describe clinical characteristics, Intensive Care Unit (ICU) utilization and in-hospital mortality from 26 urban, suburban and rural-serving hospitals in an integrated health system in Texas. Known predictors of poor prognosis in COVID-19 include older age, male sex, metabolic risk factors (dyslipidemia, obesity, diabetes) and respiratory failure requiring oxygen support. Compared with hospitalized patients &amp;lt; 85 years, oldest-old patients more often had 4+ chronic conditions (31% vs 12%, p&amp;lt; 0.0001), but less often had metabolic risk factors associated with increased risk for mechanical ventilation and mortality. Specifically, diabetes prevalence was similar between age groups (27% oldest-old vs 30%, NS), while obesity prevalence was lower (18% oldest-old vs 55%, p&amp;lt; 0.0001). Oxygen support requirements were largely similar to the general population, with 4 of 5 hospitalized patients requiring oxygenation support. Of 1,510 oldest-old patients hospitalized for SARS-CoV-2, 269 (18%) required admission to an ICU, 1,206 (80%) required oxygen support, and 1,221 (81%) survived. Following hospitalization, 78% required supportive care, including hospice (15%). Hospitalization characteristics across the lifespan suggest an accelerated and compounded need for ICU recovery and post-hospitalization rehabilitation attributed to the COVID-19 pandemic.

270: IMPACT OF COVID-19 PANDEMIC IN ICU AND HOSPITAL RESOURCE UTILIZATION: A CANCER CENTER EXPERIENCE

Introduction: A recent global study including 81 reports reported a significant drop in healthcare utilization mostly outpatient visits, admissions, diagnostics, therapeutics, and emergency services after the COVID-19 pandemic. Interestingly, these reports seldomly address intensive care utilization or mortality. We hypothesized that the pandemic significantly affected the ICU and hospital utilization rates in a comprehensive cancer center located in Houston, Texas. Methods: We conducted an observational study comparing two periods, pre-pandemic (period-A, from 3/01/2019 to 2/28/2020) and first year of the pandemic (period-B, from 3/01/2020 to 2/28/2021). We reviewed the hospital metrics in our electronic health record (EHR). Results: During the two study periods we found a 22% decrease in the overall number of hospital admissions from 46,725 admissions (period-A) to 36,615 admissions (period-B). Emergency service visits (period-A 28,357 versus period-B 21,229) dropped by 25% in period-B. There was a 15% drop in the absolute number of intensive care unit (ICU) non-COVID admissions from 2,511 (period-A) to 2,147 (ICU admission rate period-B), as well as a 15% drop in surgeries and invasive interventions from 48,687 (period-A) to 41,650 interventions (period-B). However, the ICU admission rate increased from 5.4% (period-A) to 5.9% (period-B) (p=0.001). ICU mean length-of-stay (LOS) (4.14 vs 3.82, p=0.001) and mean intubation days (5.8 vs 4.7, p=0.001) were higher in period-A. The mean hospital LOS was 8 days, the same in both periods. ICU mortality was 14.9% during period-A and 14.2% in period-B (p=0.5). Hospital mortality was 2.6% in both periods. Conclusions: Our results confirmed that overall hospital utilization rates decreased during the first year of the COVID-19 pandemic. However, despite the lower numbers of patients the proportion of ICU admissions increased, the LOS and ventilator days decreased, and mortality remained the same. These findings highlight the complexity of critical care dynamics during the pandemic.

Mechanical thrombectomy versus catheter directed thrombolysis in patients with pulmonary embolism: A multicenter experience.

Compare in-hospital outcomes of patients treated with either mechanical thrombectomy (MT) or catheter directed lysis (CDL) in treatment of acute pulmonary embolism (PE). This is a multicenter, retrospective cohort study of patients undergoing MT or CDL for acute PE between 2014 and 2021.The primary outcome was the composite of in-hospital death, significant bleed, vascular complication, or need for mechanical support post-procedure. Secondary outcomes included the individual components of the composite outcome in addition to blood transfusions, invasive hemodynamics, echocardiographic data, and intensive care unit(ICU) utilization. 458 patients were treated for PE with 266 patients in the CDL arm and 192 patients in the MT arm. The primary composite endpoint was not significantly different between the two groups with CDL 12% versus MT 11% (p = 0.5). There was a significant difference in total length of ICU time required with more in the CDL group versus MT (3.8 ± 2.0vs. 2.8 ± 3.0 days, p = 0.009). All other secondary end points showed no significant difference between the groups. In patients undergoing catheter directed treatment of PE, there was no difference between MT and CDL in terms of in-hospital mortality, bleeds, catheter-related complications, and hemodynamics.

Locoregional anesthesia is associated with reduced hospital stay and need for intensive care unit care of elective endovascular aneurysm repair patients in the Vascular Quality Initiative

ObjectiveIt has been shown local or regional anesthetic techniques are a feasible alternative to general anesthesia for endovascular aortic aneurysm repair (EVAR). However, studies to date have shown controversial findings with respect to the benefit of locoregional anesthesia (LR) in the elective setting. The objective of this study is to compare postoperative outcomes between LR and general anesthesia (GA) in the setting of elective EVAR, using a large, multicenter database. MethodsUsing the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed all patients who underwent elective EVAR from August 2003 to June 2021. Patients were grouped by anesthetic type based on the level of consciousness afforded by the anesthetic: local or regional anesthesia (LR) vs GA. Primary outcomes were total postoperative hospital length-of-stay (LOS) and intensive care unit (ICU) LOS. Propensity score matching was used for risk adjustment and to analyze the primary outcomes with confirmatory analysis using logistic or linear regression, as appropriate, in single and multilevel models. Secondary outcomes were 30-day mortality, 1-year mortality, postoperative outcomes, operative time, fluoroscopy time, and reoperation rate. These were analyzed following propensity score matching as well as using logistic regression and Cox proportional hazard regression in single and multilevel models, as appropriate. ResultsA total of 50,809 patients underwent elective EVAR from 2003 to 2021. Of these, 4302 repairs used LR (8.5%) and 46,507 (91.5%) were performed under GA. After employing propensity score matching, two groups of 3027 patients were produced. These showed no significant difference in 30-day mortality (odds ratio, 1.22; P = .53), 1-year mortality (hazard ratio, 1.06; P = .62), or any postoperative outcomes. LR was found to be significantly associated with shorter hospital stays (≤2 days) (12.5% vs 14.8%; P = .01), decreased ICU utilization (19.3% vs 30.6%; P < .001), decreased operative time (110.8 vs 117.3 minutes; P < .001), decreased fluoroscopy time (21.0 vs 22.7 minutes; P < .001), and a slight reduction in reoperation rate (1.2% vs 1.9%; P = .02), which all remained significant following single-level and multilevel multivariate analyses accounting for hospital and physician random effects. ConclusionsThese data suggest that LR anesthesia is safe and may offer advantages in reducing resource utilization for patients undergoing elective EVAR, primarily based on associations with reduced ICU care and reduced hospital stay. Given these findings, LR may prove an advantageous technique in appropriately selected patient populations.

A dynamic transmission model to calculate vaccination coverage needed to control COVID-19 in Germany

Abstract Background Control of the 2019 coronavirus disease (COVID-19) pandemic in Germany and return to pre-pandemic behaviour can only be achieved through natural or vaccine-induced immunity. Sufficient vaccine capacity promotes interest in the necessary and feasible target vaccination coverage. Methods An age and risk group stratified SEIR transmission model was used to assess the impact of vaccination coverage ranging 65%-95% for 12-59-year-olds and 90%-95% for ≥ 60-year-olds on COVID-19 incidence and intensive care unit (ICU) utilization between 01.07.2021-31.03.2022. Separate implementation of licensed vaccines allows to consider different efficacies, delivery rates and age-specific national vaccination recommendations. The analysis was conducted under different assumptions about contact behaviour during summer, reduction of daily contacts with increasing number of cases, daily vaccination uptake and the dominant variant. Data from the COVIMO study (N = 3004, data collection: 17.05.-09.06.2021) were used to define the population percentage willing to be vaccinated. Results The COVIMO study indicates an achievable vaccination compliance rate of 83.9% among 12-59-year-olds and 94.8% among those ≥ 60-year-olds. Maximum incidence or ICU utilization during observation period decreases from 385 to 61 and 6220 to 2800, respectively, with an increase in vaccination coverage from 65% to 95% of 12-59-year-olds, 90% vaccination rate among ≥ 60-year-olds, compared to pre-pandemic reduced contact behaviour in summer and reduction of contacts as case numbers increase. Conclusions The vaccination campaign should be continued at high intensity until at least 85% of 12-59-year-olds or 90% of ≥ 60-year-olds are fully vaccinated against COVID-19. Based on the population's willingness to be vaccinated, this goal seemed feasible. Key messages • Mathematical modeling was used to determine an evidence-based target vaccination coverage of ≥ 85%. • Expertise in modeling should be further strengthened.

Should the COVID-19 lockdown be relaxed or intensified in case a vaccine becomes available?

Immediately after the start of the COVID-19 pandemic in Early 2020, most affected countries reacted with strict lockdown to limit the spread of the virus. Since that time, the measures were adapted on a short time basis according to certain numbers (i.e., number of infected, utilization of intensive care units). Implementing a long-term optimal strategy was not possible since a forecast when R&D will succeed in developing an effective vaccination was not available. Our paper closes this gap by assuming a stochastic arrival rate of the COVID-19 vaccine with the corresponding change in the optimal policy regarding the accompanying optimal lockdown measures. The first finding is that the lockdown should be intensified after the vaccine approval if the pace of the vaccination campaign is rather slow. Secondly, the anticipation of the vaccination arrival also leads to a stricter lockdown in the period without vaccination. For both findings, an intuitive explanation is offered.

Plethora of Antibiotics Usage and Evaluation of Carbapenem Prescribing Pattern in Intensive Care Units: A Single-Center Experience of Malaysian Academic Hospital.

Excessive antibiotic consumption is still common among critically ill patients admitted to intensive care units (ICU), especially during the coronavirus disease 2019 (COVID-19) period. Moreover, information regarding antimicrobial consumption among ICUs in South-East Asia remains scarce and limited. This study aims to determine antibiotics utilization in ICUs by measuring antibiotics consumption over the past six years (2016–2021) and specifically evaluating carbapenems prescribed in a COVID-19 ICU and a general intensive care unit (GICU) during the second year of the COVID-19 pandemic. (2) Methods: This is a retrospective cross-sectional observational analysis of antibiotics consumption and carbapenems prescriptions. Antibiotic utilization data were estimated using the WHO Defined Daily Doses (DDD). Carbapenems prescription information was extracted from the audits conducted by ward pharmacists. Patients who were prescribed carbapenems during their admission to COVID-19 ICU and GICU were included. Patients who passed away before being reviewed by the pharmacists were excluded. (3) Results: In general, antibiotics consumption increased markedly in the year 2021 when compared to previous years. Majority of carbapenems were prescribed empirically (86.8%). Comparing COVID-19 ICU and GICU, the reasons for empirical carbapenems therapy in COVID-19 ICU was predominantly for therapy escalation (64.7% COVID-19 ICU vs. 34% GICU, p < 0.001), whereas empirical prescription in GICU was for coverage of extended-spectrum beta-lactamases (ESBL) gram-negative bacteria (GNB) (45.3% GICU vs. 22.4% COVID-19 ICU, p = 0.005). Despite microbiological evidence, the empirical carbapenems were continued for a median (interquartile range (IQR)) of seven (5–8) days. This implies the need for a rapid diagnostic assay on direct specimens, together with comprehensive antimicrobial stewardship (AMS) discourse with intensivists to address this issue.

Measurement of Procalcitonin as an Indicator of Severity in Patients With Chronic Obstructive Pulmonary Disease Admitted With Respiratory Illness.

IntroductionExacerbations of chronic obstructive pulmonary disease (COPD) are a frequent reason for hospital admission and a major cause of morbidity and mortality. A useful biomarker or indicator of disease severity at the time of presentation could help guide treatment and identify those with poor prognosis who need early aggressive intervention. We hypothesized that patients who present to the hospital with COPD exacerbations who are found to have elevated procalcitonin (PCT) levels will have worse outcomes such as longer admissions, increased intensive care unit (ICU) utilization, and more frequent readmissions than those with normal levels, regardless of presence or absence of infiltrate on initial chest X-ray (CXR).MethodsWe conducted a retrospective chart review of patients admitted to our facility with a respiratory complaint and a diagnosis of COPD to examine the relation between PCT and disease severity. A total of 156 unique encounters were reviewed, with 87 included in the final data set. Data was collected on baseline medical conditions as well as clinical status at the time of presentation. Primary endpoints included the need for overnight ICU admission, hospital length of stay greater than seven days, and repeat visit within 30 days of discharge. Secondary endpoints included the need for intubation at the time of admission, in-hospital mortality or discharge to hospice, and ICU length of stay.ResultsPatients with elevated PCT levels (>0.25ng/mL) had a significantly increased likelihood of a need for ICU admission (odds ratio 3.18) and hospital length of stay greater than seven days (odds ratio 3.38). There was no statistically significant difference in the Emergency Department readmission rate or any of the secondary outcomes.ConclusionsOur data suggests that PCT may be a useful early biomarker for patients with COPD presenting with an acute respiratory illness.