Intermediate Intensive Care Unit Research Articles

Formal guidelines from an expert panel: intensive care unit medical staffing, organisation and working hours to improve quality of life at work in France

BackgroundIntensive care units (ICU) are characterized by high medical assistance costs and great complexity. Recommendations to determine the needs of medical staff are scarce, generating appreciable variability. The French Intensive Care Society (FICS) and the French National Council of Intensive Care Medicine (CNP MIR, Conseil National Professionel de Médecine Intensive Réanimation) have established a technical committee of experts, the purposes of which were to draft recommendations regarding staffing needs in ICUs and to propose optimal organisation of work hours, a key objective being improved workplace quality of life.ResultsLiterature analysis was conducted according to the GRADE methodology (Grade of Recommendation Assessment, Development and Evaluation). The synthesis work of the experts according to the GRADE method led to the development of 22 recommendations in 6 field. The experts issued a strong recommendation associated with a high level of evidence which is that work organization be given priority during periods of permanent care, with a maximum 16 h of consecutive work permitted. For 21 other recommendations, the level of evidence did not allow GRADE classification, and led to the formulation of expert opinions. All recommendations and expert opinions were validated (strong agreement).ConclusionThe work in the intensive care unit and in the intermediate intensive care unit is multifaceted, both clinical and non-clinical, and must include at least the following continuity and quality for patient safety. This document provides a detailed framework to propose an optimal medical staff.

Subclinical left ventricular dysfunction demonstrated by strain imaging echocardiography in moderate to severe COVID-19 patients (Delta variant, single center study)

Abstract Background Cardiovascular complications in acute coronavirus disease 2019 (COVID-19) are well established and are the main contributors to morbidity and mortality. The echocardiographic investigation in these patients upon hospitalisation for COVID-19 infection, however, is relatively constrained due to the high contagiousness risk. Recent studies (1,2) have shown the subclinical myocardial dysfunction defined by left ventricular longitudinal strain (LV-GLS) but these studies were limited the number of patients. Numerous moderate to severe COVID-19 patients in our hospital were subjected to echocardiographic examination during admission in the delta variant period (full screening protocol). Therefore, this beneficial data ought to be made available to the public health. Objectives This study aims to demonstrate the prevalence of subclinical left ventricular (LV) dysfunction by strain imaging echocardiography, defined as LV-GLS, and its correlation to cardiac and inflammatory biomarkers in COVID-19 patients during admission in the delta variant era. Methods Retrospective historical review was performed from the track-care system. Post-processing analysis of strain imaging by speckle tracking echocardiography (STE) using Tomtec imaging system, COVID-19 patients who admitted in the intermediate care unit or intensive care unit and obtaining echocardiographic study during hospital stay with optimal echocardiographic imaging to provide STE (according to EACVI/ASE 2015 consensus)³ during April 2021 to March 2022, were enrolled into the study. LV-GLS > -18% was defined as subclinical LV dysfunction. We described the number and percentage of patients who had decreased left ventricular ejection fraction (LVEF) and expressed it in relation to the decreased LV-GLS and normal LV-GLS (Table 1). The correlation between LV-GLS and biomarkers (troponin-I, C-reactive protein, and interleukin-6) was analysed by Pearson correlation. Results Initially, 247 patients with COVID-19 confirmed by RT-PCR and having an echocardiogram were enrolled, but only 176 patients with adequate echocardiographic imaging (44.3% female) and a mean age of 69.1 ± 16.8 were analysed by an experienced cardiologist. Of 24 patients (13.6%) had decreased LVEF and all of patients in this group had decreased LV-GLS (-9.28% ±.3.7%). 98 of 152 patients (64.5%) in normal LVEF group had decreased LV-GLS (-14.1% ±.3.1%). The correlation between LV-GLS and biomarkers revealed only troponin-I had statistically significant correlation with LV-GLS (r = 0.52, p < 0.001), but C-reactive protein and interleukin-6 were not exhibited significant correlation with LV-GLS (r = 0.11, p = 0.17 and r = 0.09, p= 0.38, respectively). Conclusions Subclinical LV dysfunction as demonstrated by LV-GLS was not uncommon in patients with moderate to severe COVID-19 infection (delta variant era), especially if the patients had elevated cardiac troponin levels.Proportion of decreased LV-GLS in COVIDImpaired LV-GLS and troponin I level

Ventilatory support and inflammatory peptides in hospitalised patients with COVID-19: A prospective cohort trial.

Several studies have shown that SARS-CoV-2 can induce a massive release of cytokines which contributes to disease severity and mortality. Therefore, cytokine levels in the serum may help to predict disease severity and survival in COVID-19 patients. In this prospective trial, 88 patients who were hospitalised for COVID-19 were enrolled. Blood samples for serum peptide measurements were taken at the time closest to hospitalisation, at day 5, 9 and 13 (±1). The concentrations of cytokines (IL-1α, IL-1β, IL-1RA, IL-6, L-7, L-10, IFN-γ and TNF-α), chemokines (CCL-3, CCL-4 and CCL-7) and growth factors (G-CSF, GM-CSF and VEGF) were assessed and correlated with the type of ventilation, occurrence of consolidations on imaging and the level of care. COVID-19 patients (median age 68 years, IQR 55-77) stayed in hospital between 5-171 days. Compared to patients in the general care unit, patients in the intermediate care unit (IMCU) and intensive care unit (ICU) presented significantly elevated serum IL-6 (p = 0.004) and lower IFN-γ levels (p = 0.005), respectively. The peak inspiratory pressure in ventilated patients correlated positively with IL-1RA, G-CSF and inversely with IFN-γ serum levels (all p<0.05). VEGF serum levels inversely correlated with the fraction of inspired oxygen in patients receiving high-flow nasal canula oxygen therapy (p = 0.047). No significant correlation between serum concentrations of the measured peptides and the type of ventilation, occurrence of radiological consolidations or in-hospital mortality has been observed. IL1-RA, IL-6, IFN-γ, G-CSF, CCL-7 and VEGF serum levels could prove helpful as biomarkers to assess disease severity and the need for intensive care in COVID-19 patients.

Decreasing Pressure Injuries on an Adult Inpatient Unit through Implementation of a Nutrition Assessment and Management Process.

To lower the rate of hospital-acquired pressure injuries (HAPIs) by identifying at-risk patients based on the Braden Scale score, evaluating nutrition using a Mini Nutrition Assessment (MNA) tool, and implementing nutrition improvement measures. There were three steps in this intervention. First, patients with a Braden Scale score of 18 or lower were identified as being at risk for HAPI. Next, the MNA screening tool was implemented to identify nutrition deficiencies. The MNA screening tool can predict malnutrition, HAPI development, and/or additional complications. It is validated, cost-effective, and easy to administer to patients who are hospitalized with HAPI complications. In the final step, the author implemented a multicomponent nutrition intervention to improve the nutrition status of patients at risk for developing HAPI. Included patients (N = 205) were hospitalized in the intermediate ICU, had a Braden Scale score of 18 or lower, and had poor nutrition status. There was a 74% decrease in HAPI rate following the MNA nutrition screening and management, with HAPI incidence decreasing from 1.9% preintervention to 0.5% postintervention. Categorizing patients who are at risk for developing HAPI, assessing for nutrition deficiency, and then implementing a multicomponent nutrition intervention considerably reduced the rate of HAPIs per number of patients admitted to the unit.

Evaluation of the Prevalence of Barotrauma and Affecting Factors in Patients with COVID-19 during Follow-Up in the Intermediate Care Unit.

It is known that pneumothorax (PX) and pneumomediastinum (PM) develop due to COVID-19 disease. The objective of our study was to determine the prevalence of PX/PM due to COVID-19 in the intermediate intensive care unit (IMCU) and to evaluate the factors causing barotrauma and also the clinical outcomes of these patients. A total of 283 non-intubated patients with COVID-19 pneumonia followed up in the IMCU in a 1-year period were included in the study. The patients were classified as group 1 (having barotrauma) and group 2 (without barotrauma). The rate of barotrauma was 8.1% (n = 23, group 1). PX developed on the right hemithorax in 12 (70.6%) patients. Group 1 had statistically significantly higher 28-day mortality rates compared with group 2 (p = 0.014). The eosinophil and d-dimer levels of the patients in group 1 were higher, while C-reactive protein (CRP), fibrinogen, and albumin levels were lower than Group 2 (p < 0.001, p = 0.017, p = 0.001, p < 0.001), and p < 0.001, respectively). The similar rates of NIMV administration in our study groups support that barotrauma is not the only mechanism in the development of PX/PM. The findings of high blood eosinophil count and low blood levels of CRP, albumin, and fibrinogen in the barotrauma group of our study might be a pathfinder for future studies.

S689 Utilization of Risk Stratification Scores to Triage Patients With GI Bleed: A Retrospective Cohort Analysis

Introduction: Gastrointestinal (GI) bleeding affects 30-40 per 100,000 hospitalized patients annually. Many of these patients can have severe bleeding with hemodynamic instability and rapid clinical deterioration, often requiring higher levels of care such as intermediate units (IU) or intensive care units (ICU). This study aimed to compare various risk stratification tools with patient outcomes to find which tools can best help providers triage patients most appropriately on admission. Methods: This is a single-center retrospective cohort analysis of patients admitted to IU or ICU with GI bleeding as their primary diagnosis from March, 2015 - March, 2021. Medical records of patients above 18 years of age were reviewed for baseline characteristics, lab values, 30-day mortality, and 90-day readmission. Charlson comorbidity index (CCI), Glasgow-Blatchford Bleeding Score (GBS), AIMS 65, Assessment of Blood Consumption (ABC), quick Sequential Organ Failure Assessment (qSOFA) scores on admission were calculated. Patients were compared according to the level of care. Pearson Chi-square and Mann Whitney U were applied to compare groups. (Figure) Results: Out of 299 patients admitted with GI bleeding, 195 (65.2%) were admitted to IU and 104 (34.8%) to ICU. Baseline characteristics are illustrated in Table. As for treatment, antibiotics (28.8% ICU vs. 10.3% IU; p< 0.01) and PRBC transfusions (median: 3.0 ICU vs. 2.0 IU; p< 0.01) were more frequently utilized in ICU. Outcome variables assessed included need for endoscopic intervention, time to scope, and 90-day readmission rates; no significant difference was seen between groups. Patients admitted to the IU had lower 30-day mortality (p=0.02). Out of the five scores assessed, GBS, AIM-65, and qSOFA were noted to be statistically significant with score being higher in patients admitted to ICU: median (interquartile range (IQR))– GBS: 12 (9, 14.75) vs. 11.00 (8, 13); p< 0.05; AIM-65: 1 (1,2) vs. 1(0,2); p< 0.01, and qSOFA: 0(0,1) vs. 0(0,1); p< 0.01.No significant difference was noted between the median (IQR) CCI and ABC scores between ICU vs. IU: CCI: 5(3,7) vs. IU: 5 (3,7); p >0.05 and ABC: 0 (0,1) vs. IU: 0 (0,1); p >0.05. Conclusion: Our study highlights the utility of scoring tools including GBS, qSOFA, and AIM-65 to assist with triaging GI bleed patients to an appropriate level of care. The scores should be calculated at the time of admission for GI bleed patients and those with elevated scores may benefit from closer monitoring in the ICU. Table 1. - Illustrating the comparison of baseline characteristics, medical history, end organ damage (troponin leak and AKI), 30-day mortality, and 90-day readmission rates, between the patients admitted to intensive care unit and intermediate level of care ICU, n (%) = 104 (34.8%)IU n, (%) = 195 (65.2 p-value Age, mean ± SD (median, IQR) 65.56 ±14.64 (65.50, 55.25-77.00) 68.75±15.71 (71.00, 57.00-80.00) 0.078 GenderMaleFemale 57 (54.8%)47 (45.2%) 113 (57.9%)82 (42.1%) 0.601 RaceCaucasianBlackHispanicOther including data unavailable 69 (66.3%)11 (10.6%)7 (6.7%)17 (16.4%) 126 (64.6%)32 (16.4%)16 (8.2%)21 (10.8%) 0.476 History of HTN 56 (53.8%) 125 (64.1%) 0.155 History of DM 29 (27.9%) 51 (26.2%) 0.747 History of CAD 25 (24%) 78 (40%) 0.006 History of HF 32 (30.8%) 49 (25.1%) 0.296 History of CKD 27 (26%) 53 (27.2%) 0.821 History of Liver disease 23 (22.1%) 35 (17.9%) 0.482 History of DVT/PE 5 (4.8%) 23 (11.9%) 0.047 Personal history of GI tract cancer 10 (9.6%) 24 (12.3%) 0.593 Family history of GI tract cancer 5 (4.8%) 14 (7.2%) 0.625 Use of NSAIDs 17 (16.7%) 23 (12.1%) 0.280 Use of anticoagulants 40 (39.2%) 61 (31.8%) 0.201 Use of antiplatelets 30 (29.4%) 60 (31.1%) 0.766 Use of PPI at home 30 (29.4%) 69 (36.1%) 0.377 Troponin leak 12 (11.5%) 11 (5.6%) 0.172 AKI 48 (46.2%) 46 (23.6%) < 0.001 Antibiotics 30 (28.8%) 20 (10.3%) < 0.001 No. of PRBCs, mean ± SD (median, IQR) 3.29 ±2.64 (3.0, 2-4) 2.13 ±2.61 (2.0, 0-3) < 0.01 Endoscopic intervention 41 (39.4%) 59 (30.3%) 0.110 Time to scope, mean ± SD (median, IQR) 1.35±1.78 (1.0, 0.75-2.00) 1.72±1.46 (1.0, 1-2) 0.051 Alive at 30 days 81 (77.9%) 171 (88.1%) 0.020 90-day readmission due to GI Bleed 17 (16.3%) 41 (21%) 0.330 ICU – Intensive Care Unit; HTN – Hypertension; DM – Diabetes mellitus; CAD – coronary artery disease; HF – Heart Failure; AF – Atrial Fibrillation; CKD – Chronic Kidney Disease; DVT – Deep venous thrombosis; PE – Pulmonary embolism; NSAIDs – Non steroidal anti-inflammatory drugs; PPI – Proton Pump Inhibitors; AKI – Acute Kidney Injury; PRBC – Packed Red Blood Cells.

Adult hospitalizations from immigration detention in Louisiana and Texas, 2015-2018.

Poor health conditions within immigration detention facilities have attracted significant concerns from policymakers and activists alike. There is no systematic data on the causes of hospitalizations from immigration detention facilities or their relative morbidity. The objective of this study, therefore, was to analyze the causes of hospitalizations from immigration detention facilities, as well as the percentage of hospitalizations necessitating ICU or intermediate-ICU (i.e, "step-down") admission and the types of surgical and interventional procedures conducted during these hospitalizations. We conducted a cross-sectional study of statewide adult (age 18 and greater) hospitalization data, with hospitalizations attributed to immigration facilities via payor designations (from Immigration and Customs Enforcement) and geospatial data in Texas and Louisiana from 2015-2018. Our analysis identified 5,215 hospitalizations of which 887 met inclusion criteria for analysis. Average age was 36 (standard deviation, 13.7), and 23.6% were female. The most common causes of hospitalization were related to infectious diseases (207, 23.3%) and psychiatric illness (147, 16.6%). 340 (38.3%) hospitalizations required a surgical or interventional procedure. Seventy-two (8.1%) hospitalizations required ICU admission and 175 (19.5%) required intermediate ICU. In this relatively young cohort, hospitalizations from immigration detention were accompanied with significant morbidity. Policymakers should mitigate the medical risks of immigration detention by improving access to medical and psychiatric care in facilities.

Influence of working conditions and salary on temporary agency work for intermediate care and intensive care units : Partial results of anationwide survey

HintergrundLeiharbeit in der Pflege wird als Arbeitsform verwendet, um offenen Personalstellen in Kliniken zu begegnen. Sowohl Krankenhausträger als auch Pflegekräfte sehen dies aus unterschiedlichen Gründen kritisch.ZielZweck dieser Untersuchung war es herauszufinden, welches persönliche Nettoeinkommen Pflegekräfte von deutschen Intensivstationen und Intermediate-Care-Stationen als „gerecht und ausreichend“ für ihre Tätigkeit empfinden und welchen Einfluss das Gehalt auf die Wechselwilligkeit in die Leih‑/Zeitarbeit bzw. wieder zurück in eine Festanstellung haben.MethodeVon September bis Oktober 2020 wurde eine anonymisierte Onlineumfrage unter Pflegenden von Intermediate-Care-Stationen, Intensivstationen und Funktionsbereichen im deutschsprachigen Raum durchgeführt. Die Auswertung erfolgte mittels deskriptiver Statistik.ErgebnisVon 1203 Teilnehmer_innen (TN) konnten 1036 (86 %) in Deutschland Arbeitende ausgewertet werden. Die Frage nach dem persönlichen Nettoeinkommen wurde von 1032 (99 %) TN beantwortet. Der überwiegende Anteil der Befragten (n = 522) gibt an, über ein persönliches Nettoeinkommen von 2000–2999 €/Monat zu verfügen. Der Wunsch, in die Leiharbeit zu gehen, ist in der untersuchten Stichprobe geringer, je höher das persönliche Nettoeinkommen ist. Die TN in Festanstellung ohne Nebenerwerb empfinden ein persönliches Nettoeinkommen von 3200 €/Monat (Median 3200 €; IQR 2800–3800 €) als ausreichend und gerecht für ihre Tätigkeit. Von den Leiharbeiter_innen gaben 142 Personen an, dass ein persönliches Nettoeinkommen von 3200 €/Monat (Median 3200 €; Interquartilsabstand 3000–3950 €) ausreichend wäre, um von der Leiharbeit zurück in eine Festanstellung zu wechseln.SchlussfolgerungDie Intensivpflegenden dieser Umfrage empfinden ein Gehalt von 3200 €/Monat netto als ausreichend und gerecht für ihre Tätigkeit. Die Gehaltshöhe kann ein Parameter für die Entscheidung sein, in die Leiharbeit zu gehen, aber auch um wieder in die Festanstellung zu wechseln. Unabhängig vom Gehalt wurden bessere Arbeitsbedingungen für alle befragten Gruppen als essenzieller Bestandteil in Bezug auf die Arbeitszufriedenheit angegeben.

Uniquely Vulnerable – Children in Immigration Detention

The needs of children detained at the southern border of the United States have attracted much attention and often heated discussion. Physicians reported significant ethical concerns and called for more transparency around care in detention facilities. 1 Crosby S.S. Annas G.J. Border babies – medical ethics and human rights in immigrant detention centers. N Engl J Med. 2020; 383: 297-299 Crossref Scopus (0) Google Scholar The American Academy of Pediatrics has promulgated a policy advocating for appropriate and compassionate care and outlining specific recommendations for post-release services. 2 Linton J.M. Griffin M. Shapiro A.J. Detention of immigrant children. Pediatrics. 2017; 139e20170483 Crossref PubMed Scopus (90) Google Scholar Pediatric Hospitalizations from Immigration Detention in Texas, 2015-2018The Journal of PediatricsVol. 244PreviewAlthough there are concerns regarding children's health in immigration detention, there are little data regarding hospitalizations in this population. Using 2015-2018 Texas inpatient data, we identified 95 hospitalizations of children in detention and found that most (60%) were driven by infectious causes, and that 37% of these children were admitted to an intensive care unit (ICU) or intermediate ICU. Full-Text PDF Open Access

Abnormal Circadian Blood Pressure Variation is Associated with SYNTAX Scores in Hospitalized Patients with Acute Coronary Syndrome.

ResumoFundamento Menor redução da pressão arterial (PA) noturna, conhecida como hipertensão não-dipper, é um forte preditor de morbimortalidade cardiovascular.Objetivos Este estudo visou investigar a relação entre a hipertensão não-dipper e a gravidade e complexidade da doença arterial coronariana usando o escore SYNTAX em pacientes hospitalizados com síndrome coronariana aguda.Métodos Foram selecionados 306 pacientes consecutivos com síndrome coronariana aguda. Pacientes clinicamente estáveis internados na unidade de terapia intensiva intermediária pelo menos 24 horas após a angiografia e/ou revascularização bem sucedida. Após os critérios de exclusão, foram incluídos 141 pacientes (34 mulheres e 107 homens; idade média 61 ± 11 anos). A hipertensão não-dipper foi definida como uma queda de 0% a 10% na PA sistólica média durante a noite em comparação com o dia, medida em intervalos de 1 hora, usando o mesmo dispositivo automático de medição de PA em monitores de beira de leito (Vismo PVM-2701; Nihon Kohden Corp., Tóquio, Japão). O escore SYNTAX foi calculado com uma calculadora online. Os preditores independentes do escore SYNTAX foram avaliados por meio de análise de regressão logística multivariada. P < 0,05 foi considerado estatisticamente significativo.Resultados Os pacientes com hipertensão não-dipper apresentaram escore SYNTAX maior do que os pacientes com hipertensão dipper (11,12 ± 6,41 versus 6,74 ± 6,45, p < 0,0001). Em um modelo de regressão logística multivariável, o status de hipertensão não dipper (odds ratio: 5,159; intervalo de confiança de 95%: 2,246 a 11,852, p < 0,001), sexo (p = 0,012) e colesterol de lipoproteína de baixa densidade (p = 0,008) emergiram como preditores independentes de alto escore SYNTAX.Conclusões Os resultados do nosso estudo fornecem um possível mecanismo adicional ligando o perfil anormal da PA circadiana à gravidade e à complexidade da doença arterial coronariana em pacientes com síndrome coronariana aguda.

Assessment of level of care recommendations and nursing acuity scores following an appropriateness of care intervention

BackgroundAs part of a multiprong intervention to eliminate waste in cost of hospital accommodations, the InterQual Level of Care (LOC) criteria was deployed by our institution to assign patients to...

Early Prediction of Intensive Care Admission in Emergency Department Patients With Asthma.

Emergency physicians must choose whether patients with asthma are admitted to a hospital ward or a higher level of care, such as an intermediate care unit (IMC) or intensive care unit (ICU). This study aimed to determine which variables, available early during emergency department (ED) visits, are associated with IMC/ICU admission. In this retrospective chart review (records from 2015-2018), two trained abstractors, blinded to study hypothesis, abstracted data on predictor variables and disposition (ward vs. IMC/ICU). Predictor variables were defined explicitly and abstracted from the periods of ED arrival and after treatment with 7.5 mg nebulized albuterol. Distress was defined as tripod positioning or speaking in broken sentences. "Arrival" and "after treatment" scoring systems were derived based on adjusted odds ratios (aOR) for predictor variables. We performed analyses using SASⓇ, version 9.4 (SAS Institute). Among 273 patients, 105 required admission to an IMC/ICU. At presentation, distress (aOR 2.1, 95% confidence interval [CI] 1.1-3.9), room air SpO2 ≥95% (aOR 0.29, 95% CI 0.14-0.62), respiratory rate > 20 breaths/min (aOR 1.9, 95% CI 1.0-3.3), and retractions (aOR 1.9, 95% CI 1.1-3.3) were associated with IMC/ICU admission. After initial bronchodilator therapy, heart rate > 120 beats/min (aOR 7.1, 95% CI 2.0-25), room air SpO2 ≥ 95% (aOR 0.15, 95% CI 0.07-0.34), and noninvasive ventilation (aOR 6.5, 95% CI 2.5-17) were associated with IMC/ICU admission. Both scoring systems stratified risk of IMC/ICU admission into low-risk (9-10%) and high-risk (70-100%) groups. Combinations of predictor variables, available early in a patient's stay, stratify risk of admission to an IMC/ICU bed.

Premorbid Clinical Frailty Score and 30-day mortality among older adults in the emergency department.

ObjectivesThe association between frailty and short‐term prognosis has not been established in critically ill older adults presenting to the emergency department. We sought to examine the association between premorbid frailty and 30‐day mortality in this patient population.MethodsThis is a retrospective observational study on older adults aged over 75 who were triaged as Level 1 resuscitation with subsequent admissions to intermediate units or intensive care units (ICUs) in a single critical care center, from January to December 2019. We excluded patients with out‐of‐hospital cardiac arrest or those transferred from other hospitals. Frailty was evaluated by the Clinical Frailty Scale (CFS) from the patients’ chart reviews. The primary outcome was 30‐day mortality, and we examined the association between frailty scored on the CFS and 30‐day mortality using a multivariable logistic regression model with CFS 1–4 as a reference.ResultsA total of 544 patients, median age: 82 years (interquartile rang 78 to 87), were included in the study. Of these, 29% were in shock and 33% were in respiratory failure. The overall 30‐day mortality was 15.1%. The adjusted risk difference (95% confidence interval [CI]) in mortality for CFS 5, CFS 6, and CFS 7–9 was 6.3% (‐3.4 to 15.9), 11.2% (0.4 to 22.0), and 17.7% (5.3 to 30.1), respectively; and the adjusted risk ratio (95% CI) was 1.45 (0.87 to 2.41), 1.85 (1.13 to 3.03), and 2.44 (1.50 to 3.96), respectively.ConclusionThe risk of 30‐day mortality increased as frailty advanced in critically ill older adults. Given this high risk of short‐term outcomes, ED clinicians should consider goals of care conversations carefully to avoid unwanted medical care for these patients.

The relationship between time of delivery and composite outcomes in women who sent to the intermediate intensive care unit after delivery

The relationship between time of delivery and composite outcomes in women who sent to the intermediate intensive care unit after delivery Abstract Objective: In this study, we evaluated the effects of delivery time on maternal-fetal outcomes by evaluating patients who were taken to the gynecological intermediate intensive care unit according to their delivery hours. Material and Methods: This study cohort included 292 women aged 18-45 years, whom we followed up in the postpartum gynecological intermediate intensive care unit. We divided the patients into three groups according to the time they gave birth. Those who gave birth between 08:00-16.00 formed group1, those who gave birth between 16:00-24:00 group2, and those who gave birth between 24:00-08:00 formed group 3. We compared all collected data between groups. Result: Hysterectomy (45(36%)) and blood transfusion (35(28%)) rates in the first group were higher than the other groups (p &lt;0.001). Drain placement rates were higher in group 3 (48 (84.2%), p&lt;0.001). No other operative approach and complications were significantly different between the three groups. Conclusion: Regarding maternal-fetal outcomes and surgical complications, making the delivery outside of working hours or after 24:00 may not have a negative effect.

The characteristics of heart failure in patients with diabetes mellitus in Sanglah Hospital Denpasar

Background: The prevalence of heart failure (HF) is 4 times higher in patients with diabetes mellitus (DM) than general population. Coronary heart disease (CHD), hypertension, DM, obesity, smoking and atrial fibrillation are risk factors for HF. However, many observational studies have shown that DM is an independent risk factor for HF through the mechanism of diabetic cardiomyopathy. Objective: This study aimed to determine the characteristic heart failure in patients with DM. Methods: This study used a cross sectional descriptive design and the secondary data originating from medical records of patient in the intermediate ward and intensive care coronary care unit, Sanglah Hospital on March 2020 - March 2021. The inclusion criteria were DM patients with acute or chronic HF, while the exclusions criteria were DM patients with anemia, pregnancy and incomplete medical record data. Result: A total of 65 subjects were male (43%), aged &gt; 60 years (52.3%), had a history of smoking (50.8%), experienced obesity grade I (35.4), with duration of DM &gt; 5 years (67.7%) and had poor glycemic control (55.4%). The majority of DM complications were CHD (86.2%). Based on echocardiography results, the subjects had heart failure with reduced ejection fraction (43.1%), left atrial dilatation (58.5%), left ventricular hypertrophy (80%), heart valve abnormalities (66.2%) and left ventricular diastolic dysfunction (73.8%). Conclusion: There were no subjects who only suffered from DM type 2 without other comorbid diseases such as CHD, hypertension or heart valve disease.

Peripheral microcirculatory alterations are associated with the severity of acute respiratory distress syndrome in COVID-19 patients admitted to intermediate respiratory and intensive care units

BackgroundCOVID-19 is primarily a respiratory disease; however, there is also evidence that it causes endothelial damage in the microvasculature of several organs. The aim of the present study is to characterize in vivo the microvascular reactivity in peripheral skeletal muscle of severe COVID-19 patients.MethodsThis is a prospective observational study carried out in Spain, Mexico and Brazil. Healthy subjects and severe COVID-19 patients admitted to the intermediate respiratory (IRCU) and intensive care units (ICU) due to hypoxemia were studied. Local tissue/blood oxygen saturation (StO2) and local hemoglobin concentration (THC) were non-invasively measured on the forearm by near-infrared spectroscopy (NIRS). A vascular occlusion test (VOT), a three-minute induced ischemia, was performed in order to obtain dynamic StO2 parameters: deoxygenation rate (DeO2), reoxygenation rate (ReO2), and hyperemic response (HAUC). In COVID-19 patients, the severity of ARDS was evaluated by the ratio between peripheral arterial oxygen saturation (SpO2) and the fraction of inspired oxygen (FiO2) (SF ratio).ResultsHealthy controls (32) and COVID-19 patients (73) were studied. Baseline StO2 and THC did not differ between the two groups. Dynamic VOT-derived parameters were significantly impaired in COVID-19 patients showing lower metabolic rate (DeO2) and diminished endothelial reactivity. At enrollment, most COVID-19 patients were receiving invasive mechanical ventilation (MV) (53%) or high-flow nasal cannula support (32%). Patients on MV were also receiving sedative agents (100%) and vasopressors (29%). Baseline StO2 and DeO2 negatively correlated with SF ratio, while ReO2 showed a positive correlation with SF ratio. There were significant differences in baseline StO2 and ReO2 among the different ARDS groups according to SF ratio, but not among different respiratory support therapies.ConclusionPatients with severe COVID-19 show systemic microcirculatory alterations suggestive of endothelial dysfunction, and these alterations are associated with the severity of ARDS. Further evaluation is needed to determine whether these observations have prognostic implications. These results represent interim findings of the ongoing HEMOCOVID-19 trial.Trial registration ClinicalTrials.gov NCT04689477. Retrospectively registered 30 December 2020.

Physicians Leading Physicians: A Physician Engagement Intervention Decreases Inappropriate Use of IICU Level of Care Accommodations.

Following the adoption of an acuity-adaptable unit model in an academic medical center, a $13M increase in cost of intermediate intensive care unit (IICU) accommodations was observed. The authors followed A3 methodology to determine the root cause of this increase and developed a 3-prong intervention centered on physician engagement, given that physicians have the ability to order a patient's level of care. This intervention consisted of: (1) identifying physician champions to promote appropriate IICU use, (2) visual changes to essential electronic medical record tools, and (3) data-driven feedback to physician champions. In the year following intervention deployment, average IICU length of stay decreased from 1.08 to 0.62 days and average IICU use decreased from 21.4% to 12.3%, corresponding to ~$5.7M cost savings with no significant change in balancing measures observed. Together, these results demonstrate that a multicomponent intervention aimed at engaging physicians reduced inappropriate IICU use with no increase in adverse events.

Impact of smoking, COPD and comorbidities on the mortality of COVID-19 patients

The prognosis of the coronavirus disease 2019 (COVID-19) patients is variable and depends on several factors. Current data about the impact of chronic obstructive pulmonary disease (COPD) and smoking on the clinical course of COVID-19 are still controversial. This study evaluated the prevalence and the prognosis of COPD patients and smokers in a cohort of 521 patients admitted to four intermediate Respiratory Intensive Care Units (Puglia, Italy) with respiratory failure due to COVID-19 pneumonia. The prevalence of COPD and current smokers was 14% and 13%, respectively. COPD patients had a higher 30-day all-cause mortality than non-COPD patients. Former smokers compared to never smokers and current smokers had higher 30-day all-cause mortality. COPD patients and former smokers had more comorbidities. This study described the prevalence and the outcomes of COPD patients and smokers in a homogenous cohort of COVID-19 patients. The study showed that the prevalence of COPD and current smokers was not high, suggesting that they were not at increased risk of getting the infection. However, when SARS-CoV-2 infection occurred, COPD patients and former smokers were those with the highest all-cause mortality, which seemed to be mainly related to the presence of comorbidities and not to COPD and smoking itself.

Risk factors for transfer from Respiratory Intermediate Care Unit to Intensive Care Unit in COVID-19.

BackgroundPatients hospitalized for COVID-19-related pneumonia often need several degrees of ventilatory support, which are performed between Respiratory Intermediate Care Units (RICUs) and Intensive Care Units (ICUs), and which depend on the severity of acute respiratory distress syndrome. There is no firm consensus on transfer predictors from the RICU to the ICU.MethodsIn this retrospective observational single center study, we evaluated 96 COVID-19 patients referred to the RICU for acute respiratory failure (ARF) according to their transferal to the ICU or their stay at the RICU. We compared demographic data, baseline laboratory profile, and final clinical outcomes to identify early risk factors for transfer.ResultsThe best predictors for transfer to the ICU were elevated C-reactive protein and lymphopenia. The mortality rate was lower in the RICU than in the ICU, where transferred patients who died were mostly younger men and with less comorbidities than those in the RICU.ConclusionsFew inflammatory markers can predict the need for transfer from the RICU to the ICU. Due to the ongoing COVID-19 pandemic, we urge better clinical stratification by early and meaningful profiles in patients admitted to the RICU who are at risk of transferal to the ICU.

Nebulized Magnesium Sulphate Versus Saline as an Adjuvant in Acute Exacerbation of Chronic Obstructive Pulmonary Disease in a Tertiary Centre of Nepal: A Randomized Control Study

Introduction Magnesium has been shown to have bronchodilator properties in asthma and chronic obstructive pulmonary disease (COPD). Therapeutic benefits of nebulized magnesium in asthma has been seen. The purpose of this study was to compare therapeutic benefits of nebulised magnesium sulphate as an adjuvant with normal saline in patients with COPD exacerbation.&#x0D; MethodsIt was a randomized single blind interventional study of 172 cases of acute exacerbation of COPD presenting (AECOPD) with a peak expiratory flow rate (PEFR) &lt;300 L/min measured 20 min after initial management. Patients received 5 mg salbutamol mixed with 3 ml isotonic magnesium sulphate or 3 ml normal saline on three occasions at 30 min intervals via nebulizer. The primary outcome measured was PEFR at 90 min and hospital admission, noninvasive or invasive ventilation and mortality were taken as secondary outcomes.&#x0D; ResultsThe mean PEFR were 86.3±11.9 l/min, 97.6±19.1 l/min and 99.6±15.2 l/min after nebulization with magnesium sulphate and 79.17±14.11 l/min, 90.17±18.27 l/min and 93.17±20.63 l/min at 30, 60 and 90 minutes respectively in normal saline group which were statistically significant differences. Total 91.9% were admitted in ward and 8.1% got admitted in Medical and intermediate intensive care units from magnesium group and 81.7% were admitted in ward and 18.3% required ICU admissions in saline group. Differences in ventilation and mortality were insignificant.&#x0D; ConclusionNebulized magnesium sulphate as an adjuvant to salbutamol treatment in the setting of AECOPD has therapeutic benefit on PEFR but no effect in terms of hospital admission, requirement of invasive or non-invasive ventilation and mortality.