Intensive Care Unit Research Articles

Fast-Track Extubation Protocol for Adult Cardiac Surgery Patients to Reduce Intubation Times and Length of Stay in the Intensive Care Unit.

Prolonged intubation has been associated with unfavorable outcomes after cardiac surgery. A standardized approach is needed to ensure prompt extubation and shorten intensive care unit stays. This quality improvement project was designed to evaluate the impact of a fast-track extubation protocol on time to extubation and intensive care unit length of stay. The intervention group consisted of 26 adult cardiac surgery patients who underwent the fast-track extubation protocol. A Mann-Whitney test was used to compare time to extubation and intensive care unit length of stay in this group with those of a pair-matched control group of patients from the previous year who did not undergo the fast-track extubation protocol. An evidence-based literature review was used to develop a fast-track extubation protocol involving extubation in less than 6 hours. An educational activity was created to improve intensive care unit staff members' knowledge of the fast-track extubation protocol, and its effectiveness was measured by a posttest score of 80%. The percentage of patients with extubation times of less than 6 hours was significantly higher in the fast-track extubation protocol group than in the pair-matched control group (U = 179, P = .003). The mean intensive care unit stay decreased from 2.92 days in the control group to 1.85 days in the fast-track extubation protocol group. Implementing a fast-track extubation protocol for adult cardiac surgery patients shortened time to extubation and intensive care unit stay, expediting and improving recovery processes in the intensive care unit.

Explainable machine learning and online calculators to predict heart failure mortality in intensive care units.

This study aims to develop explainable machine learning models and clinical tools for predicting mortality in patients in the intensive care unit (ICU) with heart failure (HF). Patients diagnosed with HF who experienced their first ICU stay lasting between 24h and 28days were selected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The primary outcome was all-cause mortality within 28days. Data analysis was performed using Python and R, with feature selection conducted via least absolute shrinkage and selection operator (LASSO) regression. Fifteen models were evaluated, and the most effective model was rendered explainable through the Shapley additive explanations (SHAP) approach. A nomogram was developed based on logistic regression to facilitate interpretation. For external validation, the eICU database was utilized. After selection, the study included 2343 records, with 1808 surviving and 535 deceased patients. The median age of the study population was 70.00, with ~3/5 males (60.31%). The median length of stay in the ICU was 6.00days. The median age of the survival group was younger than the non-survival group (69.00 vs. 73.00), and non-survival patients spent longer time in the ICU. Seventy-five features were initially selected, including basic information, vital signs, laboratory tests, haemodynamics and oxygen status. LASSO regression determined the shrinkage parameter α=0.020, and 44 features were chosen for model construction. The linear discriminant analysis (LDA) model showed the best performance, and the accuracy reached 0.8354 in the training cohort and 0.8563 in the testing cohort. It showed satisfying area under the curve (AUC), recall, precision, F1 score, Cohen's kappa score and Matthew's correlation coefficient. The concordance index (c-index) reached 0.7972 in the training cohort and 0.8125 in the testing cohort. In external validation, the LDA model achieved approximately 0.9 in accuracy, precision, recall and F1 score, with an AUC of 0.79. Univariable analysis was performed in the training cohort. Features that differed significantly between the survival and non-survival groups were subjected to multiple logistic regression. The nomogram built on multiple logistic regression included 14 features and demonstrated excellent performance. The AUC of the nomogram is 0.852 in the training cohort, 0.855 in the internal validation cohort and 0.770 in the external validation cohort. The calibration curve showed good consistency. The study developed an LDA and a nomogram model for predicting mortality in HF patients in the ICU. The SHAP approach was employed to elucidate the LDA model, enhancing its utility for clinicians. These models were made accessible online for clinical application.

High vs low protein intake in chronic critical illness: A systematic review and meta-analysis.

Patients with persistent organ dysfunction after the first week of intensive care unit (ICU) admission are considered to have chronic critical illness (CCI). Acquired muscle weakness is a common feature of CCI that is accompanied by loss of muscle mass and electromyographic features of myopathy. Optimizing protein intake may help prevent acquired muscle weakness and/or promote muscle recovery, however, the optimal level of protein intake in CCI is uncertain and there is a lack of consensus in published nutritional guidelines. This systematic review focuses on the impact of high versus low protein intake as part of a nutritional strategy for patients with CCI. The terms "protein intake" and "critically ill" were systematically searched in PUBMED, CENTRAL (Cochrane Central Register of Controlled Trials), and WEB OF SCIENCE on 06/01/2023. We included studies that (1) enrolled critically ill adults (aged 18 years or over) who were in the ICU for more than 7 days and that compared (2) protein intake above and below 1.3 gr/kg administered by any route (enteral and/or parenteral), (3) had an intervention period that occurred primarily after the first 7 days of critical illness and (4) reported clinical outcomes including length of ICU and hospital stay, duration of invasive mechanical ventilation (IMV), mortality, ICU acquired infections, muscle mass and physical function. Studies pertaining to elective surgery, those with intervention periods shorter than 7 days or occurring primarily within the first 7 days of critical illness, those measuring only laboratory parameters as outcomes, and safety and feasibility studies were excluded. Four studies were included (N=1730) in the meta-analysis and systematic review. Higher (>1.3g/kg/d) versus lower protein intake was associated with a decrease in early mortality (defined as ICU or 28-day mortality) hazard ratio (HR) 0.42 (95% confidence interval (CI): 0.26-0.70, P<0.001), but had no impact on late mortality (defined as the latest mortality timepoint in each study): HR 0.93 (95% CI 0.76-1.15, P=0.51). There was no significant difference between intervention and control groups with respect to duration of IMV, duration of ICU or hospital stay, muscle mass, or the incidence of ICU-acquired infections. One study reported improvements in physical function at 3 and 6 months in the intervention group. After the first week of critical illness, increasing protein intake to >1.3g/kg/d may improve early mortality but not late mortality or other clinical outcomes. The small number of relevant studies and the heterogeneity of outcomes assessed, weaken these conclusions. Further studies are warranted to discern whether higher protein intake is beneficial in chronic critical illness. PROSPERO registration number: CRD42023403554; PROSPERO registration name: "The effect of higher than 1,3g/kg of protein versus lower intake in chronic critically ill patients".

A Rapid-Cycle Intervention to Enhance Patient and Family Satisfaction in the Intensive Care Unit.

Patient and family satisfaction with care in intensive care units is not reflected in Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Gaps may be unknown. In a cardiothoracic intensive care unit, patient satisfaction scores were not assessed and gaps could not be addressed. The primary aim was to obtain baseline data on patient and family satisfaction. The secondary aim was to improve identified gaps in satisfaction. A preintervention-postintervention, 2-cycle quality improvement project and a 12-month sustainability assessment were conducted to evaluate patient and family satisfaction in a cardiothoracic intensive care unit in a large academic health system from August 2022 to August 2023. The Nursing Intensive Care Satisfaction Scale was used to measure patients' satisfaction and the European Quality Questionnaire was used to measure family members' satisfaction with intensive care unit nursing care. Standardized scripting, processes for patient and family engagement during rounds, and structured communication were used to enhance patient and family engagement. At baseline (47 patients, 35 family members), overall patient and family satisfaction was high (mean [SD] satisfaction scores: patients, 87.6 [19.3]; family members, 94.6 [9.7]; P = .06). After intervention cycle 2, family members (n = 50) had high mean satisfaction scores on the Information Needs sub-scale of the European Quality Questionnaire. Family participation in rounds improved from 18.5% of rounds at baseline to 76.5% after intervention cycle 2 and was 61.5% at 12 months. Strategies that engage family members in rounds improve communication and satisfaction.

Determination of oxidative stress and copeptin levels of COVID-19 according to the clinical course.

COVID-19, caused by the novel coronavirus SARS-CoV-2, is characterized by hyperinflammation, which can trigger oxidative stress. At the same time, COVID-19 is accompanied by both psychological and physical stress. Copeptin, a novel stress marker, has been shown to predict disease outcomes in stress-induced diseases. In this study, we aimed to explore the potential of copeptin, with inflammatory and oxidative stress markers, in distinguishing between different clinical courses of COVID-19. This case-control study included 75 participants: 25 COVID-19 patients hospitalized in the intensive care unit (ICU), 25 non-ICU COVID-19 patients, and 25 healthy individuals. 64% of the ICU patients received corticosteroid treatment for 4-10 days before sampling. Serum concentrations of the study parameters were assessed by enzyme-linked immunosorbent assay (ELISA) and compared between the study groups. Serum IL-6 levels (p<0.001) were significantly higher in ICU patients compared to non-ICU patients and the control group. Serum MDA (p<0.001) and 4-HNE (p=0.027) concentrations were significantly lower in the ICU group in comparison with the other groups. Copeptin was not statistically significant. MDA (p=0.040) and 4-HNE (p=0.017) levels were significantly lower in the treated ICU group than the untreated one. Serum IL-6 levels were noticeably associated with COVID-19 severity. Corticosteroid therapy administration seemed to influence MDA and 4-HNE levels in the treated group, with no obvious influence on IL-6 and copeptin in the same cohort. This data suggests that in SARS-CoV-2 infection, corticosteroids may act through a rapid non-genomic mechanism.

ANMCO Position paper: Functional reorganization of cardiac intensive care units (CICUs) in Italy

Recently, cardiac intensive care units (CICUs) have undergone a significant transformation related to the evolution in management of acute coronary syndrome and influenced by other factors such as the epidemiological transition, the increasing complexity of clinical cases, the technological advancement, and the growth of clinical and scientific expertise of cardiologists. In the context of this evolution, a functional reorganization of CICUs in Italy has to be implemented in order to meet the changing needs of the population with cardiovascular disease requiring critical care. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) proposes this position paper for the reorganization of CICUs into three levels with increasing functional complexity, based on the hospital characteristics, the available technology, and clinical cases treated. The system would be functionally integrated into a regional CICU organization modeled on a time-dependent care network. This proposed network aims to standardize diagnostic and therapeutic protocols and establish unified data collection registries to facilitate self-assessment and support clinical research. The document delineates specific requirements for each CICU level, including the management of clinical cases, the expertise of intensive care cardiologists, the technological facilities, and the medical and nursing staff needed to ensure optimal care delivery.

Association of Lactate Levels and Mortality in Intensive Care Units

Most critically ill patients experience hemodynamic disorders that cause a decrease in blood perfusion, resulting in hypoxia that can increase lactate production. This study will examine the relationship between lactate levels and mortality in intensive care. This study uses a quantitative observational analytical method with a cross-sectional study design and using medical record data. Data analysis was carried out using an Independent T-test to see if there was a significant difference between lactate levels in the blood of dead and living subjects. This study, 154 subjects were obtained, consisting of 96 males (62.3%) and 58 females (37.7%). The average lactate level in the death group was 3.99, and the live group was 2.4 (p=0.004). Subjects with higher lactate levels have higher mortality rates. Lactate levels are one of the indicators of tissue oxygenation in critically ill patients. Hyperlactatemia is common in critically ill patients and can reflect an imbalance between local or systemic oxygen delivery and demand. Hyperlactatemia can cause lactic acidosis or metabolic acidosis and is associated with high mortality outcomes. Increased lactate levels are also associated with the development of Multiple Organ Dysfunction Syndrome (MODS). Subjects with high lactate levels are often associated with a variety of etiologies and poor prognosis, especially critical patients in the Intensive Care Unit (ICU). There was a relationship between blood lactate levels and mortality in ICU patients.

Reducing Hospital-Acquired Pressure Injuries in a Cardiothoracic Intensive Care Unit.

Hospital-acquired pressure injuries are a significant patient safety concern. The Centers for Medicare & Medicaid Services tracks hospital-acquired pressure injuries as a patient safety indicator. Health care organizations with higher-than-expected rates may incur penalties. The pressure injury prevalence rate in a cardiothoracic intensive care unit was above the National Database of Nursing Quality Indicators benchmark. The current standard of care-use of the Braden scale for pressure injury risk assessment and the SKIN (surface, keep turning, incontinence care, and nutrition) care bundle-may not adequately address the needs of the intensive care unit population. In addition, cardiac patients present a special challenge because of their disease process and the mechanical support devices used to treat patients in cardiogenic shock, which place them at risk for the development of hospital-acquired pressure injuries. A performance improvement project was carried out in the cardiothoracic intensive care unit to reduce the prevalence and incidence of hospital-acquired pressure injuries. A preintervention convenience cohort was compared with a postintervention cohort. The intervention consisted of use of the Cubbin-Jackson scale, an intensive care unit-specific risk-assessment tool, with linked interventions to prevent pressure injuries. The preintervention and postintervention cohorts consisted of 102 patients each. The pressure injury prevalence and incidence rates decreased by 67.84% and 36.43%, respectively, from before to after the intervention. The use of an intensive care unit-specific risk-assessment tool with linked interventions to prevent pressure injury can help reduce hospital-acquired pressure injuries in an intensive care unit.

Enhancing Tracheostomy Care: Knowledge Among Nurses in Intensive Care Units.

Patients requiring continuous mechanical ventilation benefit from easier airway management through tracheostomy, a standard treatment in critical care. However, gaps in nurses' comprehension of tracheostomy car can lead to complications such as infections and airway blockages. Therefore, understanding nurses' competency in tracheostomy care is essential for enhancing patient outcomes in intensive care units (ICUs). A cross-sectional study was conducted in the southern West Bank of Palestine among 237 nurses working in ICUs to assess their level of knowledge in tracheostomy care. Data were gathered via a structured questionnaire and analyzed using inferential tests and descriptive. Most nurses showed moderate knowledge of tracheostomy care, with significant differences observed based on age, gender, years of experience, and educational level. To significantly improve patient outcomes and safety in ICUs, it is imperative that nurses participate in continuous education and training programs focused on tracheostomy care.

Biochemical and Familial Factors Influencing COVID-19 Disease Progression

Introduction: COVID-19 is a global pandemic that has caused significant mortality. The disease severity varies among individuals, and the factors influencing its course remain unclear. This study aimed to investigate the influence of biochemical parameters and familial data on COVID-19 outcomes. Methods: A retrospective analysis of 122 COVID-19 patients was conducted. Patients were categorized into two groups: outpatients with mild symptoms and those admitted to the intensive care unit (ICU) and intubated. Demographic data, biochemical levels of vitamin D, vitamin B12, and magnesium, and COVID-19 outcomes of first-, second-, and third-degree relatives were collected. Results: The ICU group had a higher proportion of males (75%) and older patients (average age: 63.18±12.89 years) than the outpatient group (40% males and an average age of 45.13±13.77 years). Both groups had similar BMI, vitamin D, and vitamin B12 levels. However, magnesium levels were significantly higher in the ICU group (mean 2.25±0.3 mg/dL) than in the outpatient group (mean: 1.98±0.2 mg/dL). A significant familial relationship was identified between COVID-19 outcomes and disease course. Among the ICU patients, 25% had first-degree relatives who died from COVID- 19, compared to only 10% of the outpatient patients. Similarly, second- and third-degree relatives of ICU patients had a higher mortality rate from COVID-19 than relatives of outpatient patients. Conclusion:: Age, gender, and magnesium levels may influence COVID-19 disease severity. Familial ties (genetic relatedness) may also play a role, suggesting potential genetic predisposition. Further research is needed to validate these findings and elucidate the underlying mechanisms

The effectiveness of probiotics or synbiotics in the prevention and treatment of diarrhea among critically ill adults: a systematic review and meta-analysis

Diarrhea is one of the most common complications among patients in the Intensive Care Unit (ICU). Alongside common medical products for managing diarrhea, attention has been directed toward natural approaches, such as the use of probiotics or synbiotics supplements. The purpose of this review is to evaluate the effectiveness of probiotics or synbiotics in the prevention and treatment of diarrhea, mortality, and length of ICU stay. In adherence to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) statement, a systematic review and meta-analysis was conducted. Relevant articles were identified by searching PubMed, SpringerLink, and ScienceDirect databases. Quality assessment was done using Cochrane Collaboration's tool for randomized-controlled trials (ROB2). 6,305 articles were identified, of which 14 papers were included. Probiotics reduced the risk of diarrhea by 10%; however, the result was not statistically significant [Risk Ratio (RR) = 0.90; 95% Confidence Interval (CI): 0.77 to 1.05; P = 0.16; I2 = 29%; 13 studies]. No statistical significance was found among studies regarding reducing the duration of diarrhea, with considerable heterogeneity [RR = - 0.53; 95% CI: -1.46 to 0.41; P = 0.27; I2 = 71%, 5 studies]. Neither the length of ICU stays nor the mortality rate was affected by the use of probiotics or synbiotics. Probiotics or synbiotics appear to slightly reduce the incidence of diarrhea among ICU patients. However, this effect is considered statistically significant only after conducting sensitivity and subgroup analyses. Further high-quality clinical trials are required to evaluate the potential of probiotics or synbiotics in the treatment of diarrhea among critically ill patients.

Kinetic estimated glomerular filtration rate and drug dosing in critically ill patients with acute kidney injury-A prospective observational study.

To study the impact of kinetic glomerular filtration rate (kGFR) on clinical decision making and its implications on drug dosing compared to that of estimated GFR (eGFR) using chronic kidney disease epidemiology collaboration (CKD-EPI) equation in critically ill patients with acute kidney injury (AKI) admitted in a tertiary level intensive care unit (ICU). Cross-sectional, prospective, observational study design. All patients admitted to Medical ICU, Fortis Hospital, Bangalore with AKI defined as per AKI network (AKIN) criteria. Patients were recruited after approval from the scientific and institutional ethics committee, with written informed consent. Serum creatinine values at admission and further values were noted. GFR was calculated using both formulas (CKD-EPI and kGFR) and documented at all intervals of creatinine sampling. Drugs requiring renal dose modification along with the dosing were documented. Sample size was calculated after a pilot study and a total of 107 patients were analyzed. Incidence of AKI was 12.84%. The mean (±SD) eGFR was 37.25 (±29.4) and kGFR was 42.5 (±33.2), (p-value .003). 70 (65.42%) patients required drug dose change when kGFR was used. Dosing changes from Day 1 to Day 5 are 53/104 (50.9%), 39/81 (48.1%), 12/26 (46.1%), 2/9 (28.5%), 1/2 (50%). Predominant dose changes were for antimicrobials: vancomycin (35.7%), acyclovir (23.1%), and meropenem (23%). Drug dosing using different methods of GFR calculation showed a difference in the dosing in 65.42% of patients with AKI. Accounting for change in creatinine over time using kinetic GFR may lead to better drug dosing in critically ill patients with AKI. Our study shows that calculating GFR using kGFR formula instead of CKD-EPI may change drug dosages among patients with AKI admitted in ICU. By replacing conventional GFR estimation formulas with kGFR we may reduce the drug dosing inaccuracies that are currently prevalent in this cohort of patients.

Assessment of the Roles of Critical Care Nurses: Tool Development, Psychometric Properties, and Nurses' Perceptions.

Critical care nursing is considered one of the most challenging and demanding fields in nursing. Critical care nurses work in high-stress environments, tending to patients who are experiencing acute illness and necessitate intensive care. Nurses play a crucial role in providing nursing care for critically ill patients, encompassing duties such as assessment, administration of medications, ventilator management, diligent monitoring, and responding to life-saving situations. Despite the significance of their contributions, there are limited assessment tools used to assess critical care nurses' perceptions about their roles and responsibilities in intensive care units (ICU). The main aim of this study was to develop a tool to assess the critical care nurses' knowledge, awareness, and perception of their roles and responsibilities in the critical care units. The researcher developed the Critical Care Nurses' Roles and Responsibilities Assessment Tool. Subsequently, the tool underwent content validity assessment by five nursing experts, resulting in a final tool with 17 Likert-scale items. The scores ranged from 17 to 85, with intervals indicating varying levels of awareness. To assess the nurses' perception of the roles and responsibilities identified in the tool, a study was conducted on 120 registered nurses working in the ICU units across 9 governmental hospitals in Jordan. Data were collected through an online questionnaire covering demographical data and the roles and responsibilities of critical care nurses in the ICU. The collected data were subjected to quantitative analysis using appropriate statistical methods. Regarding the results among the experts, the content validity index (CVI) of the tool was 0.93. Among the participants, Cronbach alpha was measured to assess the reliability and internal consistency of the tool and the result was 0.912. Regarding the nurses' perception, a small percentage of participants, specifically (9%), demonstrated a moderate level of agreement with the roles and responsibilities mentioned in the tool (mean of scores=40 - 63). Conversely, a substantial majority of participants (91%), exhibited a high level of agreement (mean of scores=64 - 85). In conclusion, the results of this study revealed a powerful and reliable tool that has earned widespread acclaim among experts and participants alike.

Preoperative immunonutrition and postoperative outcomes in patients with cancer undergoing major abdominal surgery: Retrospective cohort study.

Surgical resection is a first-line treatment for patients with cancer, but preoperative malnutrition is a risk factor for postoperative complications. This study aimed to evaluate the association between preoperative administration of an immunonutrition regimen and postoperative clinical outcomes in patients with cancer undergoing major abdominal surgery. The Surgical Prehabilitation Multimodal Oncology (SUPREMO) retrospective cohort study, conducted from January 2021 to December 2023, included patients with cancer undergoing major abdominal surgery. Patients were categorized based on whether they received a complete immunonutrition regimen or an incomplete or no regimen. Demographic and clinical data were extracted from electronic health records for descriptive analysis. Logistic regression was used to assess the impact of immunonutrition on the risk of infectious complications, with clinical and demographic variables as explanatory factors. A total of 620 patients were included, with 49% receiving a complete preoperative immunonutrition regimen. Bivariate analysis indicated that complete regimen administration was associated with lower intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), and vasopressor support requirements (p=0.005, p=0.019, and p=0.032, respectively). The logistic regression model showed a significant reduction in in-hospital infectious complications (odds ratio 0.54, 95% confidence interval 0.31-0.98; p=0.044). Administering a complete preoperative immunonutrition regimen may be associated with reduced infectious complications, ICU and IMV requirements, and vasopressor support use.

Persistent Mortality Risk From Device-related Healthcare-associated Infection in Kidney Transplant Recipients Despite Multifaceted Interventions Action Calls for a Zero-tolerance Policy.

Although multifaceted control intervention actions (bundles) are highly effective in reducing the risk of device-related healthcare-associated infections (d-HAIs), no studies have explored their impact on the outcomes of kidney transplant recipients (KTRs) or the extent of risk reduction achievable through the bundle implementation. Seven hundred ninety-eight prevalent KTRs admitted to the intensive care unit (ICU) requiring invasive devices were included: 449 patients from the bundle preimplementation period and 349 from the postimplementation period. The primary outcome was mortality within 90 d of ICU admission. Using Poisson regression models, the magnitude of risk reduction for d-HAIs after the bundle implementation and the impact of d-HAIs on the risk of death was estimated. The 90-d survival rate was significantly lower in patients with d-HAIs (37.7% versus 71.7%; P < 0.001). The bundle implementation reduced the risk of d-HAIs by 58% (relative risk, 0.42; P = 0.005). Despite the significant reduction in d-HAIs after the bundle implementation, d-HAIs were associated with a 2.6-fold higher risk of death (hazard ratio [HR], 2.63; P < 0.001) regardless of the study period. Additional variables associated with increased risk of death included age (HR, 1.03; P < 0.001), baseline immunosuppression (HR based on mycophenolate versus others 0.74; P = 0.02), time since transplantation (HR, 1.003; P < 0.001), platelet count at ICU admission (HR, 0.998; P < 0.001), and sepsis as the reason for ICU admission (HR, 1.67; P < 0.001). The persistent risk associated with d-HAIs, despite the implementation of multifaceted control intervention actions in an ICU specialized in KTR care, underscores the need for a zero-tolerance policy toward d-HAIs.

ICU-Broncho-Aspiration Protocols Monitoring at an Academic Health Network System.

The objectives were to determine intensive care unit (ICU) incidence of broncho-aspiration (BA) and the effect of monitoring BA prevention protocols. The Health Network Warehouse was interrogated for the diagnosis of BA in patients older than 18 years in the surgical ICU (SICU) from January 2010 to December 2020. A BA prevention bundle protocol was prospectively monitored during all consecutive SICU admissions from August 2021 to November 2021 until discharge/death (n = 159). Experimental subjects were matched for age, sex, body mass index, and comorbidities with historical controls (BA- and BA+) as a propensity score analysis study. The BA prevention bundle protocol consisted of head-of-bed elevation at 30°, acid-suppressive medication, and daily administration of mouthwash. Univariate/multivariate analyses were conducted (P < 0.05). The BA incidence over a 10-year period was 5.6%. Before study initiation, random monitoring showed a mean bundle protocol compliance of 29% (18%-39%). After the introduction of protocol monitoring, compliance increased to 92% despite an upsurge in temporary nurses serving in the ICU. There was a total of 795 daily entries, with a mean head-of-bed elevation of 29.8° ± 13°, and a 10-fold decrease in BA (from 5.6% to 0.6%, P < 0.01). Implementation and monitoring of a BA prevention protocol significantly reduced the rate of BA in the SICU.

Hospitalizations in people with down syndrome across age groups: a population-based cohort study in Switzerland.

People with Down syndrome suffer from multiple associated diseases. However, knowledge on rates and causes of hospitalizations is limited. This population-based cohort study used national hospital claims data in Switzerland between January 1, 2012 and December 31, 2020. Included were hospitalizations of people aged 0-90 years. People with Down syndrome were identified using ICD-10-GM code Q90 and were compared to the general population. The primary outcome was the hospitalization rate. Secondary outcomes were the primary reasons for hospitalizations, secondary diagnoses, and in-hospital outcomes. Analyses were stratified by three age groups: neonates and infants (0-12 months), children and adolescents (1-17 years), and adults (18-90 years). We calculated incidence rates, risk ratios (RR), and regression coefficients with corresponding 95% confidence intervals (CI). Among 9,992,538 hospitalizations, 5697 were identified for people with Down syndrome. Hospitalization rate for people with Down syndrome was highest in the first two years of life. In the total general population, it was highest in adults beyond 60 years. Primary reasons for hospitalization among people with Down syndrome were classified as diagnoses of the circulatory system (neonates and infants: RR 13.3 [95% CI 12.0-14.6], children and adolescents: RR 3.3 [95% CI 2.7-3.9]), and infectious diseases (adults: RR 4.0 [95% CI 3.7-4.2]). At birth, individuals with Down syndrome typically had an average of six diagnoses, a number that the general population reaches, on average, by the age of 69. People with Down syndrome experienced worse in-hospital outcomes, including longer stays in both the hospital and intensive care unit by a factor of 1.7 and a higher all-cause in-hospital mortality by an overall rate difference of 1.9%. The findings underscore the medical complexity of hospitalized people with Down syndrome and emphasize the need for a comprehensive, age-inclusive approach to improve in-hospital outcomes and anticipate emergency hospitalizations across age groups. Kantonsspital Aarau AG.

End-of-life (EOL) outcomes and healthcare utilization for patients with hepatocellular carcinoma (HCC) who received immune checkpoint inhibition (ICI).

560 Background: ICI is standard of care treatment for advanced HCC. EOL outcomes for patients with HCC who receive ICI prior to death are unknown. We examine relationships between EOL outcomes, healthcare utilization, and receipt of ICI for patients with advanced HCC referred to our tertiary center. Methods: Patients with advanced HCC evaluated at our center on or after January 1, 2020 and who died by March 29, 2024 were included. Patients were identified using diagnostic codes for liver cancer and HCC, and subsequently verified by manual review of the electronic health record. Demographic data, Child-Pugh (CP) status, and treatment history were collected. Primary EOL outcomes include: documentation of advance directives and goals of care (GOC) conversations, location of death, palliative care referral, hospice referral, days in hospice, and code status. Secondary healthcare utilization outcomes include: systemic therapy receipt, emergency department (ED) visits, hospitalization, and intensive care unit (ICU) admissions within 14, 30, and 90 days of death. Outcomes were stratified by ICI or non-ICI as last therapy received and p-values were derived using Pearson’s chi-square test for equality of proportions. Results: Of 221 evaluated patients, 71 died and met criteria for analysis. Baseline characteristics include mean age 64.1 years, 70.8% male, 71.8% received systemic treatment (median 1 line, range [1-7]), 54.1% CPA, 37.5% CPB, and 8.3% CPC at the time of last treatment. No statistically significant differences in primary EOL outcomes were detected when stratified by receipt of ICI or non-ICI as last therapy. Median days enrolled in hospice were not statistically significant between groups (24.5 days [non-ICI] vs 10 days [ICI]; p = 0.39). A higher proportion of patients who received ICI as last therapy had increased healthcare utilization across all outcomes (see Table). Conclusions: Patients with advanced HCC receiving ICI as their last treatment before death compared to those receiving non-ICI had similar EOL outcomes but higher healthcare utilization. This may be due to increased real-world use of ICI in CPB patients. Further investigation into risk stratification to predict high healthcare utilizers could guide decision-making and conversations around ongoing use of ICI, particularly near the EOL. Healthcare utilization outcomes stratified by receipt of ICI. Outcome Before Death n = 71 90 days 30 days 14 days Therapy within Total: Last therapy ICI 33/71 (46.5%)69.7% 18/71 (25.4%)66.7% 6/71 (8.5%)33.3% ED visit Total: Last therapy ICI 29/71 (40.8%)58.6% 27/71 (38.0%)55.6% 22/71 (30.1%)59.1% Hospitalization Total: Last therapy ICI 32/71 (45.1%)59.4% 30/71 (42.3%)56.6% 29/71 (40.8%)58.6% ICU admission Total: Last therapy ICI 6/71 (8.5%)66.7% 6/71 (8.5%)66.7% 6/71 (8.5%)66.7%

Nurses' Experience With End-of-Life Care in Geriatric Centers: A Systematic Review.

Geriatric nurses provide end-of-life care based on the five pillars of aging. This systematic review assesses the emotions and feelings of geriatric nurses during end-of-life care. It considers the prevalence, triggers, and intensity of emotional responses among geriatric nurses. It also expounds on the strategies for overcoming the emotional challenges. The study embarked on a systematic review of literature materials on nurses' emotions and feelings. The eligibility criteria involve literature materials published in the past 5 years, peer reviews, English language, geriatric nurses, and nurses in emergency department, primary care, and intensive care unit. Three databases (Cochrane Library, PubMed, and CINAHL) and Google Scholar were used. Using a PRISMA flow chart, the literature search led to the discovery of nine significant writings on the emotions and feelings of nurses attending to geriatric patients. Sample sizes in these studies varied from 6 to 126 nurses while three articles involved integrated, scoping, and literature review of published studies. The common emotions and feelings among nurses caring for elderly patients in the geriatric center are compassion fatigue, burnout, grief, and moral distress. These emotions and feelings affect the performance of nurses. They also influence their physical and mental wellbeing. This situation calls for developing effective coping strategies to address this challenge.

Ambulation Protocol for Adult Patients Receiving Extracorporeal Membrane Oxygenation: A Quality Improvement Initiative.

For patients receiving extracorporeal membrane oxygenation, early mobility decreases mechanical ventilation time, delirium incidence, and length of intensive care unit stay and improves physical functioning. Individual centers use institutional guidelines to develop ambulation protocols. Local Problem A quality improvement initiative was used to evaluate an ambulation protocol for adult intensive care unit patients receiving extracorporeal membrane oxygenation. Adult patients receiving extracorporeal membrane oxygenation who walked according to the protocol were compared with a historical control group of patients who walked without the protocol. Data analysis included descriptive statistics and independent t tests. Outcomes included adverse safety events, number of patients and ambulation sessions, standing and ambulation time, and distance. From January to March 2021, 13 of 46 patients receiving extracorporeal membrane oxygenation (28%) walked according to the protocol. In the control group, 14 of 147 patients (10%) walked in 2019; 21 of 144 patients (15%) walked in 2020. Some characteristics of the control group (hospitalized before the COVID-19 pandemic) differed from those of the protocol group (hospitalized during the pandemic). Mean number of ambulation sessions was not significantly different between groups (protocol group, 10; control group, 9). Differences in mean standing time (protocol group, 121.23 minutes; control group, 210.80 minutes), ambulation time (protocol group, 11.77 minutes; control group, 198.70 minutes), and ambulation distance were not significant. Standing time, ambulation time, and distance were not significantly different between the groups. The extracorporeal membrane oxygenation ambulation protocol demonstrated clinical significance by increasing the number of patients walking.