Intensive Care Unit Visits Research Articles

Identifying Facilitators and Barriers to Neonatal Intensive Care Unit Visitation in Mothers of Low Socioeconomic Status: A Qualitative Investigation.

The experience of parenting in a highly medicalized, unnatural environment can result in impaired mother-infant bonding, but increased maternal presence at the infant's bedside has been associated with improved infant and maternal outcomes. The primary objective of this study was to explore barriers and facilitators during the NICU Experience in regard to maternal presence in an NICU. We interviewed 12 mothers (7 Black, 5 white) of low socioeconomic status (SES) whose preterm infants (average birth gestational age of 27 weeks) were currently hospitalized in an NICU. We engaged the NICU Family Advisory Board in all steps of the research process. Barriers and facilitators to maternal presence spanned all levels of the Socioecological Model; however, barriers were mostly at the societal, community, and institutional levels, while facilitators varied based on interpersonal and individual-level factors. Assets that mothers accessed to facilitate visits, such as free housing and shuttle services, were not available to all mothers based on individual circumstances (e.g., caregiving responsibilities). While a few mothers identified negative interactions with health care practitioners, these encounters were not attributed to racism or described as barriers to visitation. Hospitals can support families with infants in an NICU by providing free or inexpensive short-term sibling support, alleviating the burden of parking costs, and communicating early and frequently about available institutional resources during the hospital stay.

Long-term effects of flexible visitation in the intensive care unit on family members' mental health: 12-month results from a randomized clinical trial.

The aim of this study was to assess the effects of flexible intensive care unit (ICU) visitation on the 1-year prevalence of post-traumatic stress, anxiety and depression symptoms among family members of critically ill patients. This is a long-term outcome analysis of a cluster-crossover randomized clinical trial that evaluated a flexible visitation model in the ICU (12h/day) compared to a restrictive visitation model (median 1.5h/day) in 36 Brazilian ICUs. In this analysis, family members were assessed 12months after patient discharge from the ICU for the following outcomes: post-traumatic stress symptoms measured by the Impact Event Scale-6 and anxiety and depression symptoms measured by the Hospital Anxiety and Depression Scale. A total of 519 family members were analyzed (288 in the flexible visitation group and 231 in the restrictive visitation group). Three-hundred sixty-nine (71.1%) were women, and the mean age was 46.6years. Compared to family members in the restrictive visitation group, family members in the flexible visitation group had a significantly lower prevalence of post-traumatic stress symptoms (21% vs. 30.5%; adjusted prevalence ratio [aPR], 0.91; 95% confidence interval [CI] 0.85-0.98; p = 0.01). The prevalence of anxiety (28.9% vs. 33.2%; aPR 0.93; 95% CI 0.72-1.21; p = 0.59) and depression symptoms (19.2% vs. 25%; aPR, 0.78; 95% CI 0.60-1.02; p = 0.07) did not differ significantly between the groups. Flexible ICU visitation, compared to the restrictive visitation, was associated with a significant reduction in the 1-year prevalence of post-traumatic stress symptoms in family members.

A study to assess the psychosocial needs of patient family members in the intensive care unit in India.

Admission to an intensive care unit (ICU) is considered a mental crisis for patients and their families as they are unprepared for such a stressful and difficult situation. Hence, the objectives of this study are to assess the psychosocial needs of patient family members in the ICU in various dimensions such as assurance, proximity, information, support, and comfort; and to associate their psychosocial needs with their socio-demographic variables and clinical variables of the patient. This was a cross-sectional analytical study conducted between December 2021 and January 2022 among 188 family members of patients admitted to the ICU using a convenience sampling technique in a tertiary hospital in Puducherry, India. The modified Critical Care Family Needs Inventory (CCFNI) questionnaire was administered to all consenting family members to determine their needs. The overall most important need among the five dimensions of modified CCFNI scores identified by the family members is the need for assurance (2.71±0.38). Using analysis of variance, statistical significances were found as follows. Education and comfort (F-statistic and P-value): 2.76 (0.029); relationship with the patient and assurance: 2.61 (0.036); relationship with the patient and support: 2.44 (0.048); level of consciousness and comfort: 4.63 (0.010); ICU visit restriction and assurance: 3.28 (0.022); ICU visit restriction and comfort: 8.08 (<0.001). Since family members are essential members of the treatment teams, nurses should concentrate on reassuring them, assisting them in emerging from crises through appropriate communication, offering support, and attending to their needs.

The facilitators and barriers to implementing virtual visits in intensive care units: A mixed-methods systematic review.

Visitation has a positive effect on patients and families, yet, it can disrupt intensive care unit (ICU) care and increase the risk of patient infections, which previously favoured face-to-face visits. The coronavirus disease 2019 (COVID-19) pandemic has raised the importance of virtual visits and led to their widespread adoption globally, there are still many implementation barriers that need to be improved. Therefore, this review aimed to explore the use of ICU virtual visit technology during the COVID-19 pandemic and the barriers and facilitators of virtual visits to improve virtual visits in ICUs. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six databases (CINAHL, China National Knowledge Infrastructure [CNKI], PubMed, Cochrane, VIP and Wang Fang databases) were searched for empirical studies published between 1 January 2020 and 22 October 2023. Studies that investigated and reported barriers to and facilitators of implementing virtual visits in ICUs during the COVID-19 pandemic were included. Evidence from the included studies was identified and thematically analysed using Thomas and Harden's three-step approach. Study quality was appraised with the Mixed-Methods Appraisal Tool. A total of 6770 references were screened, of which 35 studies met the inclusion criteria after a full-text review. Eight main barriers to virtual visits use were identified: technical difficulties; insufficient resources; lack of physical presence and nonverbal information; low technical literacy; differences in families' perceptions of visual cues; privacy and ethics issues; inequitable access and use of virtual visit technology; and lack of advance preparation. Four facilitating factors of virtual visit use were identified: providing multidimensional professional support; strengthening coordination services; understanding the preferences of patients and their families; and enhancing privacy and security protection. In the quality appraisal of 35 studies, 12 studies were rated as low, five as medium and 18 as high methodological quality. This review identified key facilitating factors and barriers to ICU virtual visits, which can foster the development of infrastructure, virtual visiting workflows, guidelines, policies and visiting systems to improve ICU virtual visiting services. Further studies are necessary to identify potential solutions to the identified barriers.

Quality of palliative and end-of-life care: a quantitative study of temporal trends and differences according to illness trajectories in Quebec (Canada)

BackgroundOur aim was to assess temporal trends and compare quality indicators related to Palliative and End-of-Life Care (PEoLC) experienced by people dying of cancer (trajectory I), organ-failure (Trajectory II), and frailty/dementia (trajectory III) in Quebec (Canada) between 2002 and 2016.MethodsThis descriptive population-based study focused on the last month of life of decedents who, based on the principal cause of death, would have been likely to benefit from palliative care. Five PEoLC indicators were assessed: home deaths (1), deaths in acute care beds with no PEoLC services (2), at least one Emergency Room (ER) visit in the last 14 days of life (3), ER visits on the day of death (4) and at least one Intensive Care Unit (ICU) admission in the last month of life (5). Data were obtained from Quebec’s Integrated Chronic Disease Surveillance System (QICDSS).ResultsThe annual percentage of home deaths increased slightly between 2002 and 2016 in Quebec, rising from 7.7 to 9.1%, while the percentage of death during a hospitalization in acute care without palliative care decreased from 39.6% in 2002 to 21.4% in 2016. Patients with organ failure were more likely to visit the ER on the day of death (20.9%) than patients dying of cancer and dementia/frailty with percentages of 12.0% and 6.4% respectively. Similar discrepancies were observed for ICU visits in the last month and ER visits in the last 14 days.ConclusionPEoLC indicators showed more aggressiveness of care for patients with organ failure and highlight the need for more equitable access to quality PEoLC between malignant and non-malignant illness trajectories. These results underline the challenges of providing timely and optimal PEoLC.

Risk Profiles in Geriatric COVID-19 Patients: Vaccination Impacts on Hospitalization and Survival During the Omicron Wave

Introduction: The Omicron variant causes less severe disease than other variants. Although most patients experienced a mild course, an increase in hospitalizations and intensive care unit follow-ups was observed. The course of the disease was more severe, especially in the geriatric population. This study investigated the factors leading to hospitalization, intensive care needs, and mortality in older patients. Materials and method: Between October 2022 and March 2023, COVID-19 patients aged &gt; 60 years were included in the study. Patients’ demographic features, underlying diseases, initial symptoms, vaccinations, treatment, secondary bacterial infections, and COVID-19 history were investigated. Mortality rates at the hospital and after discharge were investigated. Results: Adding three or more mRNA vaccines to the vaccination schedule was associated with a reduced risk of hospitalization and intensive care unit admission. Patients with repeated vaccine doses had no mortality or intensive care unit follow-up, whereas unvaccinated patients had 13.3% mortality and 46.6% intensive care unit follow-up. 80-year-olds and older had higher mortality. The mortality rate of patients admitted to the hospital with a deteriorating general condition was considerably higher (28.8%) than that of other patients (5.4%). Patients with a COVID-19 history had fewer intensive care unit visits (10.25%). The mortality rate among hospitalized patients who did not receive molnupiravir was higher (40%) than that of those who received treatment (14%). Conclusion: Repeated vaccine doses, heterologus, and full-dose mRNA vaccination reduced mortality and hospitalization rates. Patients aged ≥80 have a higher risk of mortality. Molnupravir treatment significantly decreased the mortality rate. Keywords: COVID-19; SARS-CoV-2; Vaccination; Mortality.

Parent and grandparent neonatal intensive care unit visitation for preterm infants.

Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes. Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared. Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%). Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up.

Relationship between parental stress and post-traumatic stress disorder: The moderating effect of visitation restrictions in paediatric intensive care units during COVID-19.

Visitation restrictions due to COVID-19 kept parents from being with their children who were hospitalized in the PICU and from meeting with professional staff. This study examined the moderating effect of COVID-19-induced visitation restrictions on the relationship between stress and post-traumatic stress disorder in parents of children admitted to the paediatric intensive care unit. We conducted a descriptive, exploratory study involving 93 parents of children hospitalized in the paediatric intensive care unit using the Korean version of the Parental Stressor Scale: Paediatric Intensive Care Unit and the Revised Impact of Events Scale. Descriptive, Pearson's correlation, and logistic regression analyses were used to investigate the data. Self-reported survey questionnaires were provided for parents to complete in a separate area of the outpatient clinic when they visited for follow-up care after their children were discharged from the paediatric intensive care unit. Mothers showed significantly higher post-traumatic stress disorder scores than fathers. The relationship between all the sub-domains of perceived stress and post-traumatic stress disorder was statistically significant. Visitation restrictions because of the COVID-19 pandemic had significant moderating effects on the relationship between perceived parental stress and post-traumatic stress disorder. Moreover, the moderating effects of COVID-19 were exhibited when the two sub-domains-hyperarousal and intrusion-were investigated. Paediatric intensive care unit visitation may be an important intervention for parental post-traumatic stress disorder. Parental visitation should be enabled, and alternative interventions should be developed in situations where visitation is prohibited. It is necessary to develop and apply various and effective alternatives visitation that can prepare hospitals for visiting restrictions during pandemic situations which could emerge in the future.

Healthcare resource use in myasthenia gravis: a US health claims analysis.

There are limited data on the impact of myasthenia gravis (MG) on real-world healthcare resource use (HCRU) and patient burden in the United States. This study aims to assess HCRU in patients with MG using data from a US health claims database. A retrospective, database study of adult patients newly diagnosed with MG, using the IBM® MarketScan® Commercial Claims and Encounters and Medicare supplemental health insurance claims database. Patients with ⩾2 MG International Classification of Disease diagnosis codes ⩾3 months apart were followed from the date of their first MG diagnosis record or start of treatment. HCRU and use of immunoglobulins and plasma exchange during follow-up was assessed, as well as comorbidities, hospitalizations, emergency room (ER) visits, intensive care unit (ICU) admissions, and specialist visits per year after diagnosis, and compared with age- and sex-matched non-MG controls. During 2010-2019, 7194 patients were followed for up to 10 years (median = 2.3 years). During follow-up, patients with MG were 2.6-fold more likely than controls to be hospitalized, and 4.5-fold more likely to be admitted to an ICU. Risk and numbers of ER admission, hospitalization, and ICU visits were the highest in the 12 months post-diagnosis of MG and were consistently higher than controls during follow-up. MG was the main cause for most hospitalizations. Patients with MG have higher HCRU, compared with the age- and sex-matched non-MG controls. The early years after MG diagnosis are a period of particularly high healthcare burden, with many patients requiring hospitalization and ICU care to manage serious exacerbations.

The beliefs and attitudes of intensive care unit nurses and patient families regarding an open visitation policy in China.

To investigate the beliefs and attitudes of intensive care unit (ICU) nurses and patients' family members towards an open visitation policy in the ICU in China and to explore the reasons that promote or hinder open visitation to improve visitation policy. Open visitation policies are widely recommended in many countries. However, there are gaps between evidence and practice. Most ICUs in China still use a restrictive policy for family visits, which raises controversy. There are limited visiting times, and family visitors are not allowed to enter the ICU. A multicentre survey was conducted in seven hospitals in China. The Beliefs and Attitudes towards Visitation in the Intensive Care Unit Questionnaire (BAVIQ) was administered to ICU nurses and patient families from 11 the ICUs of seven hospitals. A total of 275 questionnaires were completed and returned by ICU nurses and 139 by patients' family members. Among nurses, the belief scale score was 2.87 ± 0.33 (range 2-4), and the attitude scale score was 5.53 ± 1.12 (range 2.33-7). The belief scale was divided into three subscales: nurses, patients, and patients' families. The subscale score for patients' families was the highest, and the nurses' subscale score was the lowest. Most (84.0%) of the nurses were satisfied with the current ICU visitation policy. The belief and attitude scores were 3.13 ± 0.39 (range 1.96-4) and 6.18 ± 1.20 (range 1.67-7), respectively, for family members. The scores of the three subscales, that is, patients, patients' families and nurses, were 3.13 ± 0.40, 3.26 ± 0.43, and 3.04 ± 0.49, respectively. Nurses' beliefs and attitudes towards implementing an open visitation policy in China are at a less positive level than those of patient family members. The beliefs and attitudes of nurses towards open visitation policy in China need to be improved. The question of how to mobilize nurses' enthusiasm for an open visitation policy poses a challenge for ICU management.

Prospective Evaluation of Infections in Geriatric Patients in Intensive Care Units.

Nosocomial infections (NIs) are major health problems with morbidity and mortality. Geriatric patients require intensive care unit (ICU) admission more frequently, and serious challenges occur during treatment. We aimed to evaluate the risk factors of NI and mortality in geriatric patients admitted to the ICU. The study was conducted between April 2018 and April 2019 in two hospitals. We prospectively recorded the data on the forms prepared according to daily ICU visits. During the study period, 600 patients were hospitalized in the ICUs. Geriatric patients constituted 446 (74.3%) of the total number. The NI rate was 59% in adult patients and 80% in geriatric patients. The most frequent NI in geriatric patients was pneumonia (42%). Furthermore, the need for mechanical ventilation support, prolongation of hospital stay, total parenteral nutrition, and tracheostomy were statistically higher in geriatric patients with NI. The mortality rate in geriatric patients was statistically higher than in non-geriatric. We found the rates of prolonged hospitalization, NI development, malignancy, and cerebrovascular disease diagnosis significantly higher in geriatric patients than in non-geriatric patients. NI and mortality rate are higher in geriatrics than in adult patients. Pneumonia is the most common type of NI in the ICU. Identification of risk factors regarding NI and mortality in geriatric patients in ICU will contribute to developing strategies for prevention.

786. Effect of Nirmatrelvir/Ritonavir versus Placebo on COVID-19─Related Hospitalizations and Other Medical Visits

Abstract Background Nirmatrelvir coadministered with ritonavir (nirmatrelvir/r) is a COVID-19 treatment. This study evaluated nirmatrelvir/r in nonhospitalized, symptomatic adults with COVID-19 at high risk of progressing to severe disease. We report secondary efficacy endpoints associated with COVID-19─related medical visits, including hospitalization details and oxygen support, as of the primary completion data cutoff (Dec 11, 2021). Methods In this phase 2/3 double-blind, interventional study, adults with confirmed SARS-CoV-2 and symptom onset ≤ 5 days (d) were randomized 1:1 to receive nirmatrelvir/r 300 mg/100 mg or placebo (PBO) orally every 12 hours for 5 d. COVID-19─related medical visits were collected through Day 28. Oxygen support for COVID-19 and details of COVID-19─related hospitalization, including duration, intensive care unit (ICU) status, and mechanical ventilation, were assessed. Results Of the 2246 patients (pts) enrolled globally from Jul to Dec2021, 2085 (nirmatrelvir/r, n=1039; PBO, n=1046) started treatment and met criteria for the modified intent-to-treat population (mITT1; ≤ 5 d of symptom onset, did not/not expected to receive a mAb). Fewer overall COVID-19-related medical visits were reported with nirmatrelvir/r vs PBO (Table 1). In addition to fewer hospitalizations being reported with nirmatrelvir/r (n=8 [0.8%]) vs PBO (n=65 [6.2%]), pts receiving nirmatrelvir/r had fewer hospitalized d (Table 2), with mean durations of 9.6 (range, 5.0, 16.0) d with nirmatrelvir/r and 11.2 (range, 2.0, 57.0) d with PBO in hospitalized pts. No pts in the nirmatrelvir/r group and 9 pts (0.9%) in PBO group were admitted to the ICU. No pts in the nirmatrelvir/r group received mechanical ventilation vs 3 pts in the PBO group. Fewer other COVID-19─related nonhospital medical visits were reported with nirmatrelvir/r vs PBO (Table 3). In the full analysis set, fewer pts required oxygen therapy for COVID-19 with nirmatrelvir/r (n=9/1120 [0.8%]) vs PBO (n=54/1126 [4.8%]). Conclusion High-risk adults with symptomatic COVID-19 treated with nirmatrelvir/r within 5 d of symptom onset had fewer COVID-19─related medical visits and reduced healthcare utilization (no ICU visits, no mechanical ventilation, fewer days in hospital) vs pts receiving PBO. Clinical Trial: NCT04960202. Disclosures Jennifer Hammond, PhD, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Heidi Leister-Tebbe, BSN, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Annie Gardner, MPH, MSPT, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Paula Abreu, PhD, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Weihang Bao, PhD, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Wayne Wisemandle, MA, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds Wajeeha Ansari, MPH, Pfizer Inc.: Stocks/Bonds Rienk Pypstra, MD, MBA, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds James M Rusnak, MD, PhD, Pfizer Inc: Employee|Pfizer Inc: Stocks/Bonds.

From Open to Closed: COVID-19 Restrictions on Previously Unrestricted Visitation Policies in Adult Intensive Care Units.

In March 2020, rising numbers of COVID-19 infections contributed to changes in intensive care unit visitation policies, with some facilities allowing no visitors. To compare visitation policies of Magnet and Pathway to Excellence hospitals with prepandemic open visitation in adult intensive care units. A mixed-methods study was conducted from January through March 2021. Quantitative data on visitation policies were extracted from websites of 96 Magnet and Pathway to Excellence hospitals that had allowed unrestricted visits in adult intensive care units before the pandemic. Qualitative data were collected via semistructured interviews with 9 nurse leaders from these hospitals. More than 1 year after the start of the pandemic, all of the hospitals had instituted restricted visitation policies. The policies varied, with little to no evidence-based justification. Restrictions included 83% of hospitals (n = 80) allowing just 1 visitor per day and 69% of hospitals (n = 50 of 72) allowing no visits at all for patients with COVID-19 in the intensive care unit. Five themes were found when nurse leaders' interviews were analyzed: visitors not welcome, doing harm, external decisions at system level, visiting within limits, and changes in critical care nursing work. Results of the study suggest that despite the vast amount of evidence supporting the benefits of visitation and the harms of restricted visitation and expert recommendations for returning safe visitation to hospitals, Magnet and Pathway to Excellence hospitals continue to enforce restricted visitation policies in intensive care units. Patients, families, and nursing and health care staff must partner to create pandemic-proof visitation policies.

Perspectives from designated family caregivers of critically ill adult patients during the COVID-19 pandemic: A qualitative interview study.

Family visitation in intensive care units (ICU) has been impacted by the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic. While studies report on perceptions of families completely restricted from ICUs, little is known about the burden experienced by designated family caregivers allowed to visit their critically ill loved one. This study sought the perspectives of family caregivers of critically ill patients on the impact of one-person designated visitor policies mandated in ICUs during the COVID-19 pandemic. Throughout the study period a restricted visitation policy was mandated capturing the first (April 2020) and second (December 2020) waves of the pandemic that allowed one designated family caregiver (i.e., spouses or adult children) per patient to visit the ICU. Designated family caregivers of critically ill patients admitted to ICU September 2020 to November 2020 took part in individual 60-minute, semi-structured interviews at 6-months after discharge from the index ICU admission. Themes from family interviews were summarized with representative quotations. Key themes identified following thematic analysis from six participants included: one visitor rule, patient advocate role, information needs, emotional distress, strategies for coping with challenges, practicing empathy, and appreciation of growth. Designated family caregivers of critically ill patients admitted to ICU during the COVID-19 pandemic perceived a complex and highly stressful experience. Support from ICU family liaisons and psychologists may help ameliorate the impact.

The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: A cross-sectional study.

BackgroundDuring the Coronavirus disease 2019 (COVID‐19) pandemic, hospital visits were suspended and video calls were offered to connect patients with their family members, especially toward the end of life (EoL).AimThe primary aim was to describe EoL care for COVID‐19 patients dying in an intensive care unit (ICU). The secondary aim was to explore whether making video calls and allowing visits was associated with lower death‐related stress in family members.DesignSingle centre cross‐sectional study. The setting was the ICU of a COVID‐19 center in northern Italy, during the first year of the pandemic. Data on patients who died in the ICU were collected; death‐related stress on their family members was measured using the Impact of Event Scale‐Revised (IES‐R). The statistical association was tested by means of logistic regression.ResultsThe study sample included 70 patients and 56 family members. All patients died with mechanical ventilation, hydration, nutrition, analgesia and sedation ongoing. Resuscitation procedures were performed in 5/70 patients (7.1%). Only 6/56 (10.7%) of the family members interviewed had visited their loved ones in the ICU and 28/56 (50%) had made a video call. EoL video calls were judged useful by 53/56 family members (94.6%) but all (56/56, 100%) wished they could have visited the patient. High‐stress levels were found in 38/56 family members (67.9%), regardless of whether they were allowed ICU access or made a video call. Compared with other degrees of kinship, patients' offspring were less likely to show a positive IES‐R score (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05 to 0.89).ConclusionsDuring the first year of the COVID‐19 pandemic, patients died without their family members at the bedside while on life‐sustaining treatment. Stress levels were high in most family members, especially in patients' spouses. Video calls or ICU visits were judged favourably by family members but insufficient to alleviate death‐related stress.Relevance for Clinical PracticeDuring a pandemic, ICU access by patients' family members should be considered, particularly as the time of death approaches. Although generally appreciated by family members, EoL video calls should be arranged together with other measures to alleviate death‐related stress, especially for the patient's spouse.

Development of a quality assurance tool for intensive care units in Lebanon during the COVID-19 pandemic.

BackgroundDuring the coronavirus disease (COVID-19) pandemic, low- and middle-income countries have rapidly scaled up intensive care unit (ICU) capacities. Doing this without monitoring the quality of care poses risks to patient safety and may negatively affect patient outcomes. While monitoring the quality of care is routine in high-income countries, it is not systematically implemented in most low- and middle-income countries. In this resource-scarce context, there is a paucity of feasibly implementable tools to monitor the quality of ICU care. Lebanon is an upper middle-income country that, during the autumn and winter of 2020–1, has had increasing demands for ICU beds for COVID-19. The World Health Organization has supported the Ministry of Public Health to increase ICU beds at public hospitals by 300%, but no readily available tool to monitor the quality of ICU care was available.ObjectiveThe objective with this study was to describe the process of rapidly developing and implementing a tool to monitor the quality of ICU care at public hospitals in Lebanon.MethodsIn the midst of the escalating pandemic, we applied a systematic approach to develop a realistically implementable quality assurance tool. We conducted a literature review, held expert meetings and did a pilot study to select among identified quality indicators for ICU care that were feasible to collect during a 1-hour ICU visit. In addition, a limited set of the identified indicators that were quantifiable were specifically selected for a scoring protocol to allow comparison over time as well as between ICUs.ResultsA total of 44 quality indicators, which, using different methods, could be collected by an external person, were selected for the quality of care tool. Out of these, 33 were included for scoring. When tested, the scores showed a large difference between hospitals with low versus high resources, indicating considerable variation in the quality of care.ConclusionsThe proposed tool is a promising way to systematically assess and monitor the quality of care in ICUs in the absence of more advanced and resource-demanding systems. It is currently in use in Lebanon. The proposed tool may help identifying quality gaps to be targeted and can monitor progress. More studies to validate the tool are needed.

A Prospective Study of the Serological, Clinical, and Epidemiological Features of a SARS-CoV-2 Positive Pediatric Cohort.

Background: SARS-CoV-2 was a global pandemic. Children develop a mild disease and may have a different rate of seroconversion compared to adults. The objective was to determine the number of seronegative patients in a pediatric cohort. We also reviewed the clinical–epidemiological features associated with seroconversion. Methods: A multicenter prospective observational study during September–November 2020, of COVID-19, confirmed by reverse transcription-polymerase chain reaction. Data were obtained 4–8 weeks after diagnosis. Blood samples were collected to investigate the humoral response, using three different serological methods. Results: A total of 111 patients were included (98 symptomatic), 8 were admitted to hospital, none required an Intensive Care Unit visit. Median age: 88 months (IQR: 24–149). Median time between diagnosis and serological test: 37 days (IQR: 34–44). A total of 19 patients were non-seroconverters when using three serological techniques (17.1%; 95% CI: 10.6–25.4); most were aged 2–10 years (35%, p < 0.05). Univariate analysis yielded a lower rate of seroconversion when COVID-19 confirmation was not present amongst household contacts (51.7%; p < 0.05). Conclusions: There was a high proportion of non-seroconverters. This is more commonly encountered in childhood than in adults. Most seronegative patients were in the group aged 2–10 years, and when COVID-19 was not documented in household contacts. Most developed a mild disease. Frequently, children were not the index case within the family.

Evidence-informed consensus statements to guide COVID-19 patient visitation policies: results from a national stakeholder meeting

PurposeHospital policies forbidding or limiting families from visiting relatives on the intensive care unit (ICU) has affected patients, families, healthcare professionals, and patient- and family-centered care (PFCC). We sought to refine evidence-informed consensus statements to guide the creation of ICU visitation policies during the current COVID-19 pandemic and future pandemics and to identify barriers and facilitators to their implementation and sustained uptake in Canadian ICUs.MethodsWe created consensus statements from 36 evidence-informed experiences (i.e., impacts on patients, families, healthcare professionals, and PFCC) and 63 evidence-informed strategies (i.e., ways to improve restricted visitation) identified during a modified Delphi process (described elsewhere). Over two half-day virtual meetings on 7 and 8 April 2021, 45 stakeholders (patients, families, researchers, clinicians, decision-makers) discussed and refined these consensus statements. Through qualitative descriptive content analysis, we evaluated the following points for 99 consensus statements: 1) their importance for improving restricted visitation policies; 2) suggested modifications to make them more applicable; and 3) facilitators and barriers to implementing these statements when creating ICU visitation policies.ResultsThrough discussion, participants identified three areas for improvement: 1) clarity, 2) accessibility, and 3) feasibility. Stakeholders identified several implementation facilitators (clear, flexible, succinct, and prioritized statements available in multiple modes), barriers (perceived lack of flexibility, lack of partnership between government and hospital, change fatigue), and ways to measure and monitor their use (e.g., family satisfaction, qualitative interviews).ConclusionsExisting guidance on policies that disallowed or restricted visitation in intensive care units were confusing, hard to operationalize, and often lacked supporting evidence. Prioritized, succinct, and clear consensus statements allowing for local adaptability are necessary to guide the creation of ICU visitation policies and to optimize PFCC.

Long-term Safety of Directly Discharging Patients Home from the ICU Compared to Ward Transfer.

Purpose: To evaluate the long-term safety of directly discharging intensive care unit (ICU) survivors to their home. Methods: A retrospective observational cohort of 341 ICU survivors who were directly discharged home from the ICU ("direct discharge") or discharged home ≤72 hours after ICU transfer to the ward ("ward transfer") was conducted in Regina, Saskatchewan ICUs between September 1, 2016 and September 30, 2018. The primary outcome was 90-day hospital readmission. Secondary outcomes included 30-day, 90-day, and 365-day emergency department (ED) visits, 30-day and 365-day hospital readmissions, and 365-day mortality. All outcomes were evaluated by multivariable Cox regression after adjustment for demographic and clinical characteristics. Results: Of 341 survivors (25.5% of total ICU visits), 148 (43.4%) patients were direct discharges and 193 (56.6%) were ward transfers. The median age was 46 years (interquartile range, 34-62), 38.4% were female, and 61.8% resided in Regina. Compared to the ward transfer cohort, more patients in the direct discharge cohort had at least one 90-day hospital readmission (30.4% versus 17.1% of patients, adjusted hazard ratio 2.09, 95% confidence interval 1.28-3.40, P = .003), after adjustment. Additionally, there were more 90-day ED visits (P = .045), and 30-day (P = .049) and 365-day hospital readmissions (P = .03), after adjustment. Conclusions: In Saskatchewan, direct discharge compared to ward transfer was associated with an increase in 90-day hospital readmissions, and potentially other clinical outcomes. Further study is necessary.

Delirium and Anxiety Outcomes Related to Visiting Policy Changes in the Intensive Care Unit During the COVID-19 Pandemic.

ObjectiveTo evaluate the effect of intensive care unit (ICU) visit on the incidence of delirium, delirium subtype, and anxiety level in ICU patients.MethodsTrained psychiatrists and nurses evaluated ICU patients for delirium, delirium subtypes, and anxiety. Propensity score matching (PSM) was used to retrospectively analyze the data. Then, we compared the differences in the incidence of delirium, delirium subtypes, and anxiety level before and after the ICU visit ban. Logistic regression was conducted to identify the risk factors for delirium subtypes and high anxiety levels.ResultsAfter PSM, there was no statistically significant difference in the incidence of delirium between the non-visiting and restrictive visiting groups (non-visiting 27.4% versus restrictive visiting 30.9%, p = 0.162). The proportion of hyperactive and mixed subtypes was higher in the non-visiting than in the restrictive visiting group (non-visiting 35.3 and 30.1% versus restrictive visiting 27.7 and 20.1%, p = 0.002). The anxiety level was higher in the non-visiting than in the restrictive visiting group (state-trait anxiety inventory score: non-visiting 53.46 ± 4.58 versus restrictive visiting 52.22 ± 6.50, p = 0.009). Patients who stayed in the ICU during the visit ban were more likely to have hyperactive (p = 0.005) and mixed subtype (p = 0.001) than those who did not. Moreover, patients who stayed in the ICU during the visit ban were more likely to experience high anxiety levels than those who did not (p < 0.001).ConclusionProhibition of ICU visits during COVID-19 pandemic did not affect the incidence of delirium during COVID-19 but could change the delirium subtype and raise anxiety level. Moreover, visiting prohibition was a risk factor for non-hypoactive delirium subtype and high anxiety levels. Therefore, ICU visits are important in dealing with delirium subtypes and anxiety in ICU patients.