Intensive Care Unit Capacity Research Articles

Longitudinal genomics reveals carbapenem-resistant Acinetobacter baumannii population changes with emergence of highly resistant ST164 clone

Carbapenem-resistant Acinetobacter baumannii (CRAB) is a persistent nosocomial pathogen that poses a significant threat to global public health, particularly in intensive care units (ICUs). Here we report a three-month longitudinal genomic surveillance study conducted in a Hangzhou ICU in 2021. This followed a three-month study conducted in the same ICU in 2019, and infection prevention and control (IPC) interventions targeting patients, staff and the ICU environment. Most A. baumannii isolated in this ICU in 2021 were CRAB (80.9%; 419/518) with higher-level resistance to carbapenems. This was accompanied by the proportion of global clone 2 (GC2) isolates falling from 99.5% in 2019 to 50.8% (213/419) in 2021. The phylogenetic diversity of GC2 increased, apparently driven by regular introductions of distinct clusters in association with patients. The remaining CRAB (40.2%; 206/419) were a highly clonal population of ST164. Isolates of ST164 carried blaNDM-1 and blaOXA-23 carbapenemase genes, and exhibited higher carbapenem MIC50/MIC90 values than GC2. Comparative analysis of publicly available genomes from 26 countries (five continents) revealed that ST164 has evolved towards carbapenem resistance on multiple independent occasions. Its success in this ICU and global capacity for acquiring resistance determinants indicate that ST164 CRAB is an emerging high-risk lineage of global concern.

Secondary Bacterial Infections in Critically Ill COVID-19 Patients Admitted in the Intensive Care Unit of a Tertiary Hospital in Romania.

Background: The outbreak of the COVID-19 pandemic caught healthcare systems in many countries unprepared. Shortages of personnel, medicines, disinfectants, and intensive care unit (ICU) capacities, combined with inadvertent use of antibiotics and emergence of drug-resistant secondary infections, led to a surge in COVID-19-related mortality. Objective: We aimed to evaluate the prevalence of secondary bacterial infections and the associated antibiotic resistance in a temporary established ICU dedicated to COVID-19 patients. We also assessed the utility of clinical and routine laboratory data as predictors of secondary infections and mortality in these patients. Methods: We examined the medical records of 243 patients admitted to the COVID-19 Medical Support Unit of Târgu Mures, Romania, between 1 August 2020 and 31 January 2021. Results: Among the 243 patients admitted to the COVID-19 Medical Support Unit of Târgu Mures between 1 August 2020 and 31 January 2021, 59 (24.3%) presented secondary infections. Acinetobacter baumannii and Klebsiella pneumoniae were the most frequent isolates (31.1% and 18.9%, respectively), most of them multidrug resistant. Chronic obstructive pulmonary disease had a higher prevalence in patients who developed secondary infections (p = 0.012). Secondary infections were associated with longer stay in the ICU and with higher mortality (p = 0.006 and p = 0.038, respectively). Conclusions: Early identification of secondary infections and proper use of antibiotics are necessary to limit the spread of multidrug-resistant microorganisms in COVID-19 patients admitted in the ICU.

Intensive care unit caseload and workload and their association with outcomes in critically unwell patients: a large registry-based cohort analysis

BackgroundToo high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU).MethodsRetrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients’ respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period.Results415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99–1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02–1.16), p = 0.008 for ≤ 50% and 1.10 (1.05–1.15), p < 0.0001 for 51–75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06–1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21–30, lower [0.88 (0.78–0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01–1.19), p = 0.035 for 31–40, 1.28 (1.02–1.60), p = 0.033 for > 40].ConclusionsIn a system with comparably high intensive care resources and mandatory staffing levels, patients’ survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.

Early vs. delayed QTc prolongation in acute poisoning: A prognostic accuracy study-A case series.

Given the limited capacity of intensive care units in many countries, it is crucial to identify reliable prognostic markers to optimize poisoning patients management and improve outcomes. This study aimed to assess the predictive value of three variables, namely the initial QTc interval (iQTc) measured within two hours of admission, the delayed QTc interval (dQTc) measured between 6 and 12 hours of entry, and the QTc interval trend over time (ΔQTc), for mortality in patients with undifferentiated poisoning. A retrospective case series was conducted on 70 patients with undifferentiated poisoning admitted to the intensive care unit (ICU) of Afzalipour Hospital between March 21, 2021, and March 20, 2023. The results of the multivariate analysis revealed that dQTc, base deficit, and creatinine were independently associated with mortality (P value < 0.001). The dQTc had the highest predictive ability, with an area under the curve (AUC) of 0.84, followed by ΔQTc with an AUC of 0.76, and iQTc with an AUC of 0.67. Additionally, the results of the Generalized Estimating Equation model with repeated measurements revealed a higher odds ratio for dQTc (OR, 6.33; 95% CI, 2.54-15.79) compared to iQTc (OR, 4.92; 95% CI, 1.71-14.17). The study concluded that monitoring the dQTc interval could provide valuable prognostic information in acute poisoning cases.

Impact of Capacity Strain on the Health Status of Patients Discharged From an Intensive Care Unit

Intensive care units (ICUs) play a vital role in hospitals and often experience capacity strain. Using data from a large teaching hospital, we empirically examine the effect of ICU capacity strain on patient discharge. We find that capacity strain has no effect on the health status of discharged patients and that capacity strain leads to a shorter length-of-stay in the ICU, but the magnitude of the effect is less than half a day in the most extreme scenarios. In post-hoc analyses, we find evidence the discharge process is expedited by starting discharges earlier in the day when capacity is strained, demonstrating that more efficient discharges can free up space without compromising patient health. In addition, we find a decrease in patient admissions during periods of capacity strain. To our knowledge, this is the first study to examine the direct relationship between ICU capacity strain and patient health at discharge, and it builds on the existing literature that has examined the effects of ICU capacity strain on proxies for patient health at discharge. We advocate that hospitals use outcome measures based on patient status at discharge to accurately assess the impact of capacity strain on quality of care. In addition, our work highlights the need for tailored research approaches and management practices for different types of ICUs, as generalizing the impact of ICU capacity strain across different settings may lead to inaccuracies.

Public health infrastructure and COVID-19 spread: An air transportation network analysis

This study examines the effectiveness of public health infrastructure, specifically hospital and Intensive Care Unit (ICU) capacities, in mitigating the spread of COVID-19 in various US counties. We use the air transportation network to quantify the risk of importing COVID-19-infected passengers to a given county in the United States. Utilizing a dataset that encompasses COVID-19 case rates, healthcare resources, and socioeconomic and transportation-related variables across multiple destination counties, we found that increased availability of hospital and ICU beds is statistically significantly associated with a reduced risk of COVID-19 spread, after controlling for origin county infection rates, travel patterns, and socioeconomic factors. These findings underline the critical role of robust healthcare infrastructure in public health crisis management and suggest targeted policy interventions to bolster healthcare capacity as a viable strategy for mitigating pandemic impacts.

Inadequate intensive care physician supply in France: a point-prevalence prospective study

BackgroundThe COVID-19 pandemic has highlighted the importance of intensive care units (ICUs) and their organization in healthcare systems. However, ICU capacity and availability are ongoing concerns beyond the pandemic, particularly due to an aging population and increasing complexity of care. This study aimed to assess the current and future shortage of ICU physicians in France, ten years after a previous evaluation. A national e-survey was conducted among French ICUs in January 2022 to collect data on ICU characteristics, medical staffing, individual physician characteristics, and education and training capacities.ResultsAmong 290 ICUs contacted, 242 responded (response rate: 83%), representing 4943 ICU beds. The survey revealed an overall of 300 full time equivalent (FTE) ICU physician vacancies in the country. Nearly two-thirds of the participating ICUs reported at least one physician vacancy and 35% relied on traveling physicians to cover shifts. The ICUs most affected by physician vacancies were the ICUs of non-university affiliated public hospitals. The retirements expected in the next five years represented around 10% of the workforce. The median number of physicians per ICU was 7.0, corresponding to a ratio of 0.36 physician (FTE) per ICU bed. In addition, 27% of ICUs were at risk of critical dysfunction or closure due to vacancies and impending retirements.ConclusionThe findings highlight the urgent need to address the shortage of ICU physicians in France. Compared to a similar study conducted in 2012, the inadequacy between ICU physician supply and demand has increased, resulting in a higher number of vacancies. Our study suggests that, among others, increasing the number of ICM residents trained each year could be a crucial step in addressing this issue. Failure to take appropriate measures may lead to further closures of ICUs and increased risks to patients in this healthcare system.

A multi-stage optimization model for managing epidemic outbreaks and hospital bed planning in Intensive Care Units

Intensive Care Unit (ICU) capacity can be significantly affected by disease outbreaks, epidemics, and pandemics, impeding the operational efficiency of healthcare systems and compromising patient care. This paper presents a multi-stage optimization approach to planning the location and distribution of ICU beds to increase accessibility and reduce mortality caused by a shortage of beds in a geographic region during epidemic events. Using a Brazilian state monthly hospital admissions due to Covid-19 from October 2020 to April 2021, we show the amount and the allocation of extra ICU beds that could reduce mortality, minimize patient travel and transportation, and increase accessibility while considering budget limitations. Our findings show coverage for 21 previously underserved municipalities, providing extra ICU beds for 69 municipalities, ranging from 880 to 1670 beds across seven months. On average, patients are displaced 56% less and access ICUs within 17 ± 2.3 kilometres (CI 95%). The strategy contributes to public health planning and the equitable allocation of hospital resources among the population.

Comparison of outcomes and characteristics of patients admitted to the ICU with COVID-19 and other community-acquired pneumonia based on propensity score matching

ObjectiveTo compare the similarities and differences between patients with Coronavirus Disease 2019 (COVID-19) and those with other community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU), utilizing propensity score matching (PSM), regarding hospitalization expenses, treatment options, and prognostic outcomes, aiming to inform the diagnosis and treatment of COVID-19.MethodsPatients admitted to the ICU of the Third People’s Hospital of Datong City, diagnosed with COVID-19 from December 2022 to February 2023, constituted the observation group, while those with other CAP admitted from January to November 2022 formed the control group. Basic information, clinical data at admission, and time from symptom onset to admission were matched using PSM.ResultsA total of 70 patients were included in the COVID-19 group and 119 in the CAP group. The patients were matched by the propensity matching method, and 37 patients were included in each of the last two groups. After matching, COVID-19 had a higher failure rate than CAP, but the difference was not statistically significant (73% vs. 51%, p = 0.055). The utilization rate of antiviral drugs (40% vs. 11%, p = 0.003), γ-globulin (19% vs. 0%, p = 0.011) and prone position ventilation (PPV) (27% vs. 0%, p < 0.001) in patients with COVID-19 were higher than those in the CAP, and the differences were statistically significant. The total hospitalization cost of COVID-19 patients was lower than that of CAP patients, and the difference was statistically significant (27889.5 vs. 50175.9, p = 0.007). The hospital stay for COVID-19 patients was shorter than for CAP patients, but the difference was not statistically significant (10.9 vs. 16.6, p = 0.071).ConclusionOur findings suggest that limited medical resources influenced patient outcomes during the COVID-19 pandemic. Addressing substantial demands for ICU capacity and medications during this period could have potentially reduced the mortality rate among COVID-19 patients.

The Global Anesthesia Workforce Survey: Updates and Trends in the Anesthesia Workforce.

There is a large global deficit of anesthesia providers. In 2016, the World Federation of Societies of Anaesthesiologists (WFSA) conducted a survey to count the number of anesthesia providers worldwide. Much work has taken place since then to strengthen the anesthesia health workforce. This study updates the global count of anesthesia providers. Between 2021 and 2023, an electronic survey was sent to national professional societies of physician anesthesia providers (PAPs), nurse anesthetists, and other nonphysician anesthesia providers (NPAPs). Data included number of providers and trainees, proportion of females, and limited intensive care unit (ICU) capacity data. Descriptive statistics were calculated by country, World Bank income group, and World Health Organization (WHO) region. Provider density is reported as the number of providers per 100,000 population. Responses were obtained for 172 of 193 United Nations (UN) member countries. The global provider density was 8.8 (PAP 6.6 NPAP 2.3). Seventy-six countries had a PAP density <5, whereas 66 countries had a total provider density <5. PAP density increased everywhere except for high- and low-income countries and the African region. The overall size of the global anesthesia workforce has increased over time, although some countries have experienced a decrease. Population growth and differences in which provider types that are counted can have an important impact on provider density. More work is needed to define appropriate metrics for measuring changes in density, to describe anesthesia cadres, and to improve workforce data collection processes. Effort to scale up anesthesia provider training must urgently continue.

A forecasting tool for a hospital to plan inbound transfers of COVID-19 patients from other regions

BackgroundIn April 2021, the province of Ontario, Canada, was at the peak of its third wave of the COVID-19 pandemic. Intensive Care Unit (ICU) capacity in the Toronto metropolitan area was insufficient to handle local COVID patients. As a result, some patients from the Toronto metropolitan area were transferred to other regions.MethodsA spreadsheet-based Monte Carlo simulation tool was built to help a large tertiary hospital plan and make informed decisions about the number of transfer patients it could accept from other hospitals. The model was implemented in Microsoft Excel to enable it to be widely distributed and easily used. The model estimates the probability that each ward will be overcapacity and percentiles of utilization daily for a one-week planning horizon.ResultsThe model was used from May 2021 to February 2022 to support decisions about the ability to accept transfers from other hospitals. The model was also used to ensure adequate inpatient bed capacity and human resources in response to various COVID-related scenarios, such as changes in hospital admission rates, managing the impact of intra-hospital outbreaks and balancing the COVID response with planned hospital activity.ConclusionsCoordination between hospitals was necessary due to the high stress on the health care system. A simple planning tool can help to understand the impact of patient transfers on capacity utilization and improve the confidence of hospital leaders when making transfer decisions. The model was also helpful in investigating other operational scenarios and may be helpful when preparing for future outbreaks or public health emergencies.

The effect of limited healthcare access on poor outcomes among hospitalized COVID-19 patients in Honduras: A single center cohort study

BackgroundThe COVID-19 pandemic has had a severe impact on the Latin American subcontinent, particularly in areas with limited hospital resources and a restricted Intensive Care Unit (ICU) capacity. This study aimed to provide a comprehensive description of the clinical characteristics, outcomes, and factors associated with survival of COVID-19 hospitalized patients in Honduras. Research questionWhat were the characteristics and outcomes of COVID-19 patients in a large referral center in Honduras? Study design and methodsThis study employed a retrospective cohort design conducted in a single center in San Pedro Sula, Honduras, between October 2020 to March 2021. All hospitalized cases of confirmed COVID-19 during this timeframe were included in the analysis. Univariable and multivariable survival analysis were performed using Kaplan-Meier curves and Cox proportional hazards model aiming to identify factors associated with decreased 30 day in-hospital survival, using a priori-selected factors. ResultsA total of 929 confirmed cases were identified in this cohort, with males accounting for 55.4 % of cases. The case fatality rate among the hospitalized patients was found to be 50.1 % corresponding to 466 deaths. Patients with comorbidities such as hypertension, diabetes, obesity, chronic kidney disease, chronic obstructive pulmonary disease and cardiovascular disease had a higher likelihood of mortality. Additionally, non-survivors had a significantly longer time from illness onset to hospital admission compared to survivors (8.2 days vs 4.7 days). Among the cohort, 306 patients (32.9 %) met criteria for ICU admission. However, due to limited capacity, only 60 patients (19·6 %) were admitted to the ICU. Importantly, patients that were unable to receive level-appropriate care had lower likelihood of survival compared to those who received level-appropriate care (hazard ratio: 1.84). InterpretationThis study represents, the largest investigation of in-hospital COVID-19 cases in Honduras and Central America. The findings highlight a substantial case fatality rate among hospitalized patients. In this study, patients who couldn't receive level-appropriate care (ICU admission) had a significantly lower likelihood of survival when compared to those who did. These results underscore the significant impact of healthcare access during the pandemic, particularly in low- and middle-income countries.

"Everything was much more dynamic": Temporality of health system responses to Covid-19 in Colombia.

This paper examines the role of temporality in the negotiation of unplanned adaptive tasks that were part of the health system response to the Covid-19 pandemic in Colombia. While research has been carried out on the temporal aspects of emergency preparedness, we argue that there is an empirical gap concerning how health care organizations responded with temporal urgency to Covid-19. The dataset (118 interviews) from which a subset of interviews were analysed for this paper was collected during the first wave of the pandemic in Colombia in 2020. Interviewees included representatives of national and regional governments, public hospitals and private clinic managers, clinicians, including physicians and nurses, laboratory directors, and academics. Narratives of two tasks are presented: reconfiguring clinical laboratories to expand the testing capacity for Covid-19 and increasing intensive care unit capacity for patients hospitalized with Covid-19. Through thematic analysis of the navigation of these tasks, the concept of "temporal shifts", which signifies how organizations use time as a resource (analogous experiences, future projections) to negotiate unplanned service changes, is developed. This study highlights how powerful stakeholders deploy past and future projections to influence others´ perceptions in the negotiation of temporal shifts: a type of change that differs from the incremental and planned types described in previous organizational literature on temporality. This shift was initiated by rapid task delegation via organizational hierarchy, but accomplished through pressured, improvised actions at the operational level. The policy and practice implications we suggest relate to addressing social and organizational effects, including consequences for stakeholder engagement and staff wellbeing, generated by organizational leaders making decisions under "time stress".

Real World Experience with a Zuma -1 Cohort 4 Adopted Approach to CRS and Icans in CAR-T Recipients

Introduction: Axicabtagene ciloleucel (axi-cel) is a chimeric antigen receptor T-cell (CAR-T) therapy approved for treatment of relapsed/refractory (R/R) large B cell lymphoma (LBCL). The registrational phase I/II ZUMA-1 study Cohorts 1 and 4 addressed toxicity management in terms of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) whereby tocilizumab and corticosteroids were deployed earlier in Cohort 4.(1,2) Although Cohort 4 consisted of only 41 patients, it demonstrated that earlier intervention resulted in significantly fewer cases of grade ≥3 CRS (2%) and ICANS (17%) and a lower cumulative dose of steroids. Furthermore, efficacy as determined by overall response rate (ORR) and complete response (CR) did not appear to be negatively impacted by earlier use of tocilizumab and corticosteroids. However, given the small number of patients in Cohort 4, concern has remained that earlier intervention may have a deleterious impact on CAR-T cell expansion, persistence, and efficacy. During the COVID-19 pandemic, with overwhelmed Intensive Care Units (ICUs) across the country, we adopted a Cohort 4 guided approach to CAR-T toxicity management with the hope of decreasing the need for ICU level of care following CAR-T infusion. Herein, we present our single-institution, real-world experience since implementing an early intervention strategy with Cohort 4 and compare it with our previous Cohort 1 axi-cel recipients in terms of toxicity (CRS, ICANS, ICU utilization) and efficacy. Methods: 119 patients receiving axi-cel CAR-T therapy for R/R LBCL are included in this single-institution, retrospective study with 70 in Cohort 1 and 49 in Cohort 4. The transition from a Cohort 1 to Cohort 4 approach occurred in March 2021. Thus, for Cohort 1 the data cut-off was February 2021 and for Cohort 4 it was after April 2021. The COVID pandemic and the lack of the ICU capacity was the initial chief rationale for transitioning to Cohort 4. This study was conducted following IRB approval and in accordance with the Declaration of Helsinki. R version 1.3.1099 (R-studio) was used for all statistical modeling. All statistical tests were 2-sided and conducted at the 0.05 level of significance. Results: The median age was 62 (22-88) years-old, 35% female gender, 76% advanced stage III-IV disease, 22% with bulky ≥10cm disease, 71% with diagnosis of Diffuse LBCL, and 26% with more than three lines of previous therapy. The median follow-up time at analysis was 1.5 years. Laboratory parameters and comorbidities did not significantly differ between groups except for a higher incidence of renal insufficiency in the Cohort 4 group (28.6% vs 4.3%, p&amp;lt;0.001) (see Table 1). The median maximum grade CRS was significantly lower for Cohort 4 (2 vs 1, p&amp;lt;0.001) although the median grade of ICANS was not different. The utilization of tocilizumab and siltuximab was similar in both groups. The duration of steroid use was comparable in both; however, the total steroid use (dexamethasone equivalent) was notably lower in Cohort 4 (110 mg vs 190 mg, p=0.026). ICU admission following CAR-T infusion was much lower in Cohort 4 (16.3% vs 60%, p&amp;lt;0.001). Most patients (&amp;gt;80%) were discharged home after CAR-T therapy and did not need placement in a rehabilitation center or long-term facility. The ORR and ongoing responses were similar in both groups with nearly 90% achieving a response and 60% with an ongoing response. The cumulative incidence of relapse, PFS, and OS were not significantly different between the groups (see Figure 1). Conclusion: The use of an early toxicity intervention strategy based upon ZUMA-1 Cohort 4 in the real world results in significantly lower high-grade CRS, decreased cumulative steroid dose, and an 73% reduction in ICU utilization without significantly impacting efficacy in terms of incidence of relapse, PFS, or OS. Our real-world experience with the adoption of a Cohort 4 strategy suggests that patient morbidity may be greatly attenuated without compromising CAR-T therapy response. However, the need for longer follow-up to evaluate the impact early use of steroids has on CAR-T persistence and PFS at &amp;gt;5 years remains.

BS P05 The Return to Bariatric Surgery Following the COVID Pandemic 2020- A Single Center Prospective Study

Abstract Background Elective surgical practice was paused in March 2020 to cope with the Covid pandemic. Bariatric surgery was amongst the first specialities to be stopped as resource allocation prioritised lifesaving service for Covid positive patients over what is considered quality of life improving procedures. It was also one of the last to be restarted due to fears of Covid infection in obese patients undergoing surgery both of which are known risk factors of mortality in Covid cases. This study describes outcomes after bariatric surgery since the weight-loss program restarted and the measures to ensure service provision and maintenance of patient safety. Methods Elective bariatric surgery restarted in June 2021; patients were managed within a ‘green’ elective pathway in a new ring-fenced elective surgical hub. All patients who had surgery from June 2021 to January 2023 in a single centre were identified from a prospectively-maintained database of operations. The outcomes were patient safety measured by Covid infection and complication rates post operatively, impacts on hospital resources measured by length of stay in hospital and HDU/ITU bed occupation, impacts on the Bariatric Surgery service measured by waiting time for surgery and cancellations, and benefits to patients measured by remission of diabetes and hypertension. Results 124 patients were included; 42 (34%) had sleeve gastrectomy and 82 (64%) had gastric bypass. There were no Covid infections/complications in this series. Median length of stay after surgery was two days with no admissions to HDU/ICU. Waiting time for surgery was &amp;gt;52 weeks at the start of the study period which has fallen to 15 weeks after listing and no operations were cancelled due to lack of beds. Post-operative outcomes were favorable and in line with national data; 87% of patients had remission of diabetes and 60% of patients were off anti-hypertensive medications one year after surgery. Conclusions The creation of dedicated ring-fenced elective surgical hub allowed the rapid restart of bariatric surgery despite the effects of the Covid-19 pandemic. This model separated elective and acute patients reducing exposure of high-risk patients. This allowed the resumption of weight-loss surgery safely as evident by the zero Covid-related complications, no additional pressure to hospital resources such as beds and intensive care unit capacity, a high-quality service with short waiting times and favorable long term outcomes. This are all signs of good practice in a resilient service and can very easily be replicated in the future whenever required.

Cohort analysis of 50% lethal area (LA50) and associating factors in burn patients based on quality improvements and health policies

Burn injuries are among the common traumatic injuries, which can be accompanied with lifelong morbidity and mortality. The Lethal Area Fifty Percent (LA50) index is another reliable outcome measurement tool that assesses the standard of medical care at burn centers. It is widely used as a benchmark for assessing the quality of burn care and is considered the percentage at which 50% of burn patients are expected to die because of burn-related injuries. We aimed to determine and compare the LA50 in burn patients admitted to Shiraz Burn Referral Centers in 2018–2021 and 2011–2018 with regard to improving the quality of special care and infection control in the new hospital. We conducted a retrospective cohort analysis on patients admitted to Amir al-Momenin Burn Injury Hospital in Shiraz, Fars, Southern Iran. Data were retrospectively gathered from March 2011 to January 2022, and subsequently analyzed with standard statistical analysis, and also multivariate and probability analysis. A total of 7382 patients with acute burns injuries were identified. Among them, 4852 (65.7%) patients were men, and the median age was 27 years [Q1–Q3 7–40; range 1–98]. Most of the patients were in the pediatric and early adulthood age range, with 76.2% being younger than 40 years old. The median TBSA was 24% [IQR 14, 43], and the median duration of hospitalization was 11 [IQR 11] days. Most injuries were secondary to flame and fire (33.5%; n = 2472). The mortality rate in our study was 19.0% (n = 1403). We evaluated our patients based on two main time intervals: March 2011 till February 2018 (n = 3409; 46.2%), and March 2018 to January 2022 (n = 3973; 53.8%). Based on multivariate analysis, the second interval of our study was significantly correlated with a more female patients, higher age, lower TBSA, less burn injuries due to scald, contact, but more frequent fire and flame injuries, and also lower mortality rate. Factors correlated with higher mortality included male gender, older age, shorter hospitalization duration, higher TBSA, etiology of fire and flame, and accidental burn injuries. A Baux score of 76.5 had a sensitivity of 81.1%, specificity of 87.3%, accuracy of 86.1% in predicting mortality among our patients. The mortality probability for the study intervals were 20.67% (SD 33.0%) for 2011–2018, and 17.02% (SD 29.9%) for 2018–2022 (P < 0.001). The LA50 was 52.15 ± 2 for all patients. This ammount was 50 ± 2% in 2011–2018, and 54 ± 2 in 2018–2022 (P < 0.001). The mean LA50 values showed significant improvements following significant modifications in our critical care for burn victims, including augmented intensive care unit capacity, prompt relocation of inhalation burn cases to the intensive care unit, establishing a well-trained multidisciplinary team, and improved infection control. To improve outcomes for burn patients in developing countries, major changes should be made in the management of burn patients and LA50 is a reliable assessment tool for evaluating the how these changes affect patient’s outcomes.

Hospital management of an epidemic in intensive care: a predictive tool for saturation

Abstract The COVID-19 epidemic has highlighted the importance of hospital resource management in exceptional health contexts. The hospital capacity of intensive care units has emerged as a determining factor in overall hospital management. The objective of this study is to create a tool for predicting the saturation status of an intensive care unit. The predictive model was developed based on a SIR compartmental model. The model was trained using hospitalization data (admissions, discharges, and capacity) from the Raymond Poincaré Hospital, AP-HP. The model parameters (transmission and recovery rates) were estimated using the least squares method. A web application, OHASiS® (Outil Hospitalier d'Analyse de Situations de Saturations), was developed using Shiny and embeds the model. The model provides a reliable prediction over 7 days of the evolution of the number of admissions and discharges in COVID-19 intensive care units. Information on capacity makes it possible to predict a possible saturation of the service. A sensitivity analysis of the model revealed no significant difference between predicted and observed attendance data. The OHASiS® tool allows for the visualization of epidemiological data and helps with medical decision-making as the epidemic evolves. It would be desirable to integrate this application into future hospital management plans. This tool could also be used during simulation exercises. Validation of the predictive model in the context of seasonal epidemics still needs to be conducted. Key messages • A SIR compartmental model was used to develop a tool for predicting the saturation status of ICU. • The web application OHASiS® can help with medical decision-making and should be integrated into future hospital management plans, though further validation is needed for use during seasonal epidemics.

Perspectives on Assessing the Flexibility of Hospitals for Crisis Mode Operations: Lessons From the COVID-19 Pandemic in the Netherlands.

The COVID-19 pandemic placed healthcare design at the heart of the crisis. Hospitals faced challenges such as rapidly increasing their intensive care unit capacity, enabling physical distancing measures, quickly converting to telehealth and telework practices, and above all, keeping patients and staff safe. Improving flexibility in hospital facility design and adaptability of hospital operations to function in "crisis mode" can be seen as ways of future-proofing for pandemics. In a design brief, flexibility is typically mentioned as an important target. Meanwhile, robustness of technical infrastructure is called for, and standardization at unit level with single-occupancy inpatient accommodation may be considered a way to enhance flexibility and adaptability in dealing with a surge in infectious patients. To future-proof facility design with pandemic preparedness and resilience in mind, this study evaluated what kinds of interventions were taken in Dutch hospital facilities and what perspectives need to be considered when hospitals operate in crisis mode. We have collected data from facility and estate professionals from 30 Dutch hospitals. Using a practice-based approach, in-depth interviewing helped uncover and compare successful operational strategies and design elements that provided the flexibility needed in the early stages of the recent crisis. As we looked at existing facilities and alterations made to allow hospitals to operate during the COVID-19 pandemic, we discovered that staff availability and adaptability were deemed crucial. We add the perspective of staff as an essential factor to be considered when future-proofing hospital facility desigr crisis mode operation.

The care of critically ill adults with COVID-19 in Ontario pediatric intensive care units.

To describe and review the experience of two pediatric intensive care units (PICUs) in Ontario, Canada, adapting and providing care to critically ill adults during the COVID-19 pandemic. At a time of extreme pressure to adult intensive care unit (ICU) capacity, two PICUs provided care to critically ill adults with COVID-19 pneumonia. Substantial yet rapid planning was required to facilitate safe delivery of critical care to adult patients while maintaining PICU services, including thoughtful development of care pathways and patient selection. To prepare clinical staff, several communication strategies, knowledge translation, skill consolidation, andsystem-adaptation mechanisms were developed. There was iterative adaptation of operational processes, including staffing models, specialist consultation, and the pharmacy. Care provided by the interprofessional teams was reoriented as appropriate to the needs of critically ill adults in close collaboration with adult ICU teams. Forty-one adults were admitted to the two PICUs over a 12-week period. In total, 36 patients (88%) received invasive ventilation, eight patients (20%) were supported with venovenous extracorporeal membrane oxygenation, and six patients (15%) received continuous renal replacement therapy. Four died in the PICU during this period. Feedback from staff included anxiety around reorienting practice to the care of critically ill adults, physical exhaustion, and psychological distress. Importantly, staff also reported a renewed sense of purpose with participation in the program. Though challenging, the experience has provided opportunity to enhance collaboration with partner institutions and improve the care of older children and adolescents in the PICU.

ICU capacity expansion under uncertainty in the early stages of a pandemic

We propose a general modular approach to support decision‐makers' response in the early stages of a pandemic with resource expansion, motivated by the shortage of Covid‐19‐related intensive care units (ICU) capacity in 2020 in Italy. Our approach uses (1) a stochastic extension of an epidemic model for scenarios of projected infections, (2) a capacity load model to translate infections into scenarios of demand for the resources of interest, and (3) an optimization model to allocate this demand to the projected levels of resources based on different values of investment. We demonstrate this approach with the onset of the first and second Covid‐19 waves in three Italian regions, using the data available at that time. For epidemic modeling, we used a parsimonious stochastic susceptible‐infected‐removed model with a robust estimation procedure based on bootstrap resampling, suitable for a noisy and data‐limited environment. For capacity loading, we used a Cox queuing model to translate the projected infections into demand for ICU, using stochastic intensity to capture the variability of the patient arrival process. Finally, we used stochastic dynamic optimization to select the best policy (when and how much to expand) to minimize the expected number of patients denied ICU for any level of investment in capacity expansion and obtain an efficient frontier. The frontier allows a trade‐off between investment in additional resources and the number of patients denied intensive care. Moreover, in the panic‐driven early days of a pandemic, decision‐makers can also obtain the time until which they can postpone action, potentially reducing investment costs without increasing the expected number of denied patients.