Intensive Care Unit Level Research Articles

Noise in a UK intensive care unit: a retrospective cohort study

Excessive noise in hospital Intensive care units (ICU) has been associated with adverse health effects and human factor impacts acknowledged to negatively affect both patients and healthcare providers. Aims: Evaluation of the acoustic environment of the Royal Liverpool University Hospital (RLUH) ICU versus WHO and UK guidelines. Methods: Noise measurements were taken from a six-bedded bay within the RLUH ICU between 15th June and 1st July 2022. This audit focussed on noise data > 87dBA, in accordance with the national exposure limit established by UK Noise Regulations. A retrospective review of relevant patients' records was conducted to identify potential noisy events during the audit period. Results: The highest and lowest LAeq value was 77.9 and 63.5dBA, respectively. All LAeq and LAmax noise measurements recorded exceeded recommended guidelines. Noise fell below recommended daytime guidelines less than 1% of the time. The top potential causes of noise were patient repositioning/personal care, medication administration and suctioning. Conclusion: Noise levels in the RLUH ICU considerably exceed national and international guidelines. These findings highlight the need to address noise pollution in the ICU setting. Hospital staff and policy makers should consider implementing strategies and interventions for noise reduction in ICUs.

Outcomes of Traumatic Brain Injury Patients Managed in a Non–Intensive Care Unit Setting

IntroductionThe management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non–intensive care unit (ICU) setting after stratifying them using the mBIG criteria. MethodsA retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. ResultsOf the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. ConclusionsSelect patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

Geriatric Trauma Intensive Care Unit Admission Guideline Is Associated With Reduction in Unplanned Intensive Care Unit Admissions

IntroductionGeriatric trauma patients experience disproportionate adverse outcomes compared to younger patients with similar injuries and represent an important target for quality improvement. Our institution created a Geriatric Trauma Intensive Care Unit (ICU) Admission Guideline to identify high-risk patients and elevate their initial level of care. The goal of implementation was reducing unplanned ICU admissions (UIAs), a recognized surrogate marker for adverse outcomes. MethodsThe Geriatric Trauma ICU Admission Guideline was implemented on July 1, 2020, at a large academic level-1 trauma center. Using trauma registry data, we retrospectively analyzed geriatric patients who met the criteria for ICU admission 2 y preimplementation and postimplementation. The main outcome was UIAs in the target geriatric population. Secondary outcomes included hospital length of stay, ICU length of stay, ventilator days, mortality, and 30-d readmissions. Characteristics between groups were compared with t-test, Mann-Whitney U test, or chi-square test. Risk-adjusted logistic and negative binomial regressions were used for the categorical and continuous outcomes, respectively. ResultsA total of 1075 patients were identified with 476 in the preimplementation and 599 in the postimplementation group. The groups were similar across most demographic and physiologic characteristics, with the exception of a higher incidence of hypertension in the preimplementation group (77.7% versus 71.6%, P = 0.02) and COVID in the postimplementation group (3.8% versus 0.4%, P < 0.001). While mechanism of injury was similar, there was a higher incidence of traumatic brain injury in the preimplementation group (35.1% versus 26.2%, P = 0.002). In the postimplementation group, there was a higher incidence ≥3 rib fractures (68% versus 61.3%, P = 0.02) and an expected increase in initial ICU level of care (69.5% versus 37.1%, P < 0.001). The odds of a UIA after guideline implementation were reduced by half (adjusted odds ratio 0.52, 95% confidence interval 0.3-0.92). There was not a significant difference in the secondary outcomes of mortality, 30-d readmission, hospital-free days, ICU-free days, or ventilator-free days. ConclusionsImplementation of the Geriatric Trauma ICU Admission Guideline was associated with a reduction in UIAs by half in the target population. There was not a significant change in hospital-free days, ICU-free days, ventilator-free days, mortality, 30-d readmission, or venous thromboembolism. Further research is needed to better refine admission guidelines, examine the association of preventative admission on delirium, and determination of criteria that would allow safe, earlier downgrade.

Defining minimum workforce standards for intensive care physiotherapy in Australia and New Zealand: A Delphi study

BackgroundIntensive care staffing guidelines provide recommendations for the safe and effective delivery of health care while recognising professional requirements of the workforce. To guide recommendations for physiotherapy staffing guidelines, profession-specific consultation is needed. ObjectivesThe objective of this study was to develop consensus-based recommendations for minimum workforce standards for physiotherapy in intensive care. MethodsA Delphi survey process was conducted involving physiotherapists from Australia and New Zealand. ResultsThe panel consisted of 65 physiotherapists in the first round and 60 in the second round (92% retention). Respondents were from both Australia (49, 76%) and New Zealand (16, 24%) who had been physiotherapists for an average of 18.8 ± 9.0 years and were primarily senior intensive care physiotherapists (44, 68%). Respondents had experience across level 3 (50, 77%), level 2 (18, 28%), and level 1 (5, 8%) adult intensive care units (ICUs), adult high-dependency units (27, 42%), and paediatric intensive care (6, 9%). A total of 42 statements were presented, with 37 reaching consensus after two rounds. After two rounds, consensus was achieved for a minimum staffing ratio in paediatric ICUs of one physiotherapist per six (1:6) beds. For adult ICUs, use of the median value of the participant's responses was supported to establish minimum staffing ratios of 1:8, 1:7, 1:6, and 1:8 for levels 1, 2, and 3 ICUs and high-dependency units, respectively. The requirement for an additional allocation for senior physiotherapist staffing for each ICU level was also established. Statements that also gained consensus included recommendations for access to on-call and weekend services for all ICU settings and the consideration of evening shifts specifically for level 3 and paediatric ICUs. ConclusionsRecommendations for minimum staffing for physiotherapy in intensive care settings were achieved and supported requirements for clinical service delivery, supervision, and training.

Association Between High Sensitivity Troponin Levels Following Pediatric Orthotopic Heart Transplantation and Intensive Care Unit Resource Utilization.

The utility of troponin levels, including high sensitivity troponin T (hs-TnT), after orthotopic heart transplant (OHT) is controversial. Conflicting data exist regarding its use as a marker of acute rejection. Few studies have examined possible associations of hs-TnT levels immediately after OHT with metrics of intensive care unit (ICU) resource utilization or risk of acute rejection. We performed a retrospective cohort chart review including all OHT recipients < 20years of age at our center between June 2019 and December 2022. Patients were divided into two groups based on supra- or sub-median initial hs-TnT levels (median 3462.5ng/L). Primary outcome was days requiring ICU-level care, secondary outcomes included days intubated, days requiring positive pressure ventilation (PPV), days on inotropic medications, actual ICU length of stay, Vasoactive Inotrope Scores (VIS) on postoperative days (POD) 0 through 7, and acute rejection at 30days and one year after OHT. Patients with higher hs-TnT required ICU level care for longer [13.5 (10-17.5) vs. 9.5 (8-12) days, p = 0.01] and spent more days intubated [6 (4-7) vs. 3 (3-5) days, p < 0.001], on PPV [9 (6-15) vs. 6 (5-8.5) days, p = 0.02], and on inotropes [11 (9-14) vs. 8 (7-11) days, p = 0.025]. VIS was only different between groups on POD7 [5 (3-7) vs. 3 (0-5), p = 0.04]. There was no difference in rejection between the groups. Higher hs-TnT immediately following pediatric OHT may predict higher ICU resource utilization, despite no difference in VIS, although it does not predict acute rejection in the first year after OHT.

Abstract WP146: Critical Care After Thrombolytic Therapy in Acute Stroke: Who Really Needs the ICU?

Introduction: Intravenous thrombolytic therapy remains the cornerstone of management in acute ischemic stroke (AIS) patients. Given the potential adverse effects of thrombolysis, patients are admitted to an intensive care unit (ICU) for close monitoring following administration. Alternative post-thrombolytic pathways may provide for safe cost-effective care in certain populations. We aimed to determine the proportion of patients treated with thrombolytics who required ICU care for reasons other than frequent neurologic monitoring and define their characteristics. Methods: We retrospectively reviewed patients ≥ 18 years of age who received TNK/ tPA for AIS at our community-based stroke center between May 2020 and August 2022. Patients were classified as requiring ICU care if they required intubation within 24 hours of admission or neurosurgical intervention, had symptomatic hemorrhagic conversion or brain compression, required a continuous infusion for hemodynamic management, or were in status epilepticus. Univariate and multivariate statistical analysis was performed. The study protocol was deemed exempt by our institutional IRB. Results: 262 patients met inclusion criteria. 54 (20.6%) required ICU level of care. Characteristics of those requiring ICU level of care are described in Table 1. Multivariate analysis showed that patients on antiplatelet or anticoagulant therapies prior to arrival (AOR: 2.205, p= 0.021) or who presented with higher initial NIH stroke scale (AOR: 1.108, p &lt; 0.001) had significantly higher likelihood of requiring ICU level of care. Conclusions: In our cohort, approximately 21% of patients required critical care. Anticoagulant or antiplatelet therapy prior to admission and greater NIH stroke scale on arrival were associated with an increased likelihood of requiring ICU level of care. Further prospective studies are indicated to assess the efficacy of alternative settings for post-thrombolytic care in selected AIS patients.

Voice use of nurses working in the intensive care unit during the COVID-19 pandemic

ObjectiveThis study aimed to investigate the voice use of nurses working in intensive care units (ICUs) and their perception of acoustic environments. Setting and sampleThe research was conducted in four different hospitals in China during the COVID-19 pandemic. A total of 60 ICU nurses were recruited for their voice use monitoring and 100 nurses participated in the survey. Research methodologyFirstly, voice-related parameters such as voice level (SPL, dB), fundamental frequency (F0, Hz), and voicing time percentage (Dt, %) were measured using a vocal monitor. To collect data, a non-invasive accelerometer was attached to the participants' necks during their working hours. Secondly, the perception of the ICU acoustic environment was assessed using semantic differential. ResultsThe results showed that nurses spoke approximately 0.9–4 dB louder to patients and colleagues in ICUs compared to quiet rooms, and their fundamental frequency (F0) significantly increased during work. The voice levels of nurses were influenced by background noise levels, with a significant correlation coefficient of 0.44 (p < 0.01). Furthermore, the background noise levels ranged from 58.1 to 73.9 dBA, exceeding the guideline values set by the World Health Organisation (WHO). The semantic differential analysis identified ‘Stress’ and ‘Irritation’ as the two main components, indicating the prevalence of negative experiences within ICUs. Implications for clinical practiceThis study highlights the potential risk of voice disorders among ICU nurses. The findings also underscore the importance of implementing strategies to reduce noise levels in ICUs to reduce voice disorders among nurses.

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial

Drug-drug interactions (DDIs) can harm patients admitted to the intensive care unit (ICU). Yet, clinical decision support systems (CDSSs) aimed at helping physicians prevent DDIs are plagued by low-yield alerts, causing alert fatigue and compromising patient safety. The aim of this multicentre study was to evaluate the effect of tailoring potential DDI alerts to the ICU setting on the frequency of administered high-risk drug combinations. We implemented a cluster randomised stepped-wedge trial in nine ICUs in the Netherlands. Five ICUs already used potential DDI alerts. Patients aged 18 years or older admitted to the ICU with at least two drugs administered were included. Our intervention was an adapted CDSS, only providing alerts for potential DDIs considered as high risk. The intervention was delivered at the ICU level and targeted physicians. We hypothesised that showing only relevant alerts would improve CDSS effectiveness and lead to a decreased number of administered high-risk drug combinations. The order in which the intervention was implemented in the ICUs was randomised by an independent researcher. The primary outcome was the number of administered high-risk drug combinations per 1000 drug administrations per patient and was assessed in all included patients. This trial was registered in the Netherlands Trial Register (identifier NL6762) on Nov 26, 2018, and is now closed. In total, 10 423 patients admitted to the ICU between Sept 1, 2018, and Sept 1, 2019, were assessed and 9887 patients were included. The mean number of administered high-risk drug combinations per 1000 drug administrations per patient was 26·2 (SD 53·4) in the intervention group (n=5534), compared with 35·6 (65·0) in the control group (n=4353). Tailoring potential DDI alerts to the ICU led to a 12% decrease (95% CI 5-18%; p=0·0008) in the number of administered high-risk drug combinations per 1000 drug administrations per patient, after adjusting for clustering and prognostic factors. This cluster randomised stepped-wedge trial showed that tailoring potential DDI alerts to the ICU setting significantly reduced the number of administered high-risk drug combinations. Our list of high-risk drug combinations can be used in other ICUs, and our strategy of tailoring alerts based on clinical relevance could be applied to other clinical settings. ZonMw.

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.

Sleep and critical illness: a review.

Critical illness and stays in the Intensive Care Unit (ICU) have significant impact on sleep. Poor sleep is common in this setting, can persist beyond acute critical illness, and is associated with increased morbidity and mortality. In the past 5 years, intensive care clinical practice guidelines have directed more focus on sleep and circadian disruption, spurring new initiatives to study and improve sleep complications in the critically ill. The global SARS-COV-2 (COVID-19) pandemic and dramatic spikes in patients requiring ICU level care also brought augmented levels of sleep disruption, the understanding of which continues to evolve. This review aims to summarize existing literature on sleep and critical illness and briefly discuss future directions in the field.

Predictors of Escalation to Intensive Care Unit Level of Care Among Admissions for Alcohol Withdrawal.

According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older had alcohol abuse disorder. Alcohol withdrawal syndrome (AWS) can be defined as a collection of physical symptoms experienced due to abrupt cessation of alcohol after long-term dependence. In instances where regular inpatient management fails to control AWS symptoms, patients are shifted to intensive care units (ICUs) for closer monitoring and prevention of life-threatening complications like withdrawal seizures and delirium tremens (DTs), labeled as severe alcohol withdrawal syndrome (SAWS). Although this represents a significant healthcare burden, minimal studies have been conducted to determine objective predictors. In this study, we aim to determine the effect of patient demographics, socio-economic status, biochemical parameters, and clinical factors on the need for escalation to ICU level of care among admissions for AWS. Our study showed that factors such as a history of DTs or alcohol-related seizures, the initial protocol of management, degree of reported alcohol usage, activation of rapid response teams, mean corpuscular value, alcohol level on admission, highest Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) scored during the hospital stay, and the total amount of sedatives used were significantly associated with escalation to ICU level of care. Clinicians must use these objective parameters to identify high-risk patients and intervene early. We encourage further studies to establish a scoring algorithm incorporating biochemical parameters to tailor management algorithms that might better suit high-risk patients.

Risk factors for acquiring Acinetobacter baumannii infection in the intensive care unit: experience from a Moroccan hospital.

Acinetobacter species are non-fermenting and ubiquitous Gram-negative coccobacilli, which in recent years have become the leading cause of healthcare-associated infections worldwide. Our objective here was to study the epidemiology and risk factors associated with Acinetobacter baumannii infections in the intensive care unit (ICU). This retrospective case-control study was conducted collaboratively between the Medical Bacteriology Department and the two ICUs of the Military Hospital of Instruction Mohammed V-Rabat over a 3 month period. We included 180 patients, of whom 60 had A. baumannii infection. We observed a male predominance in both matched groups, with a sex ratio of 1.6. The median age was 67 years [interquartile range (IQR) 59.5-77]. The median length of stay in the ICU before infection was 8.5 days (IQR 5-14). Multivariate logistic regression analysis identified the risk factors statistically associated with A. baumannii infection at the ICU level as follows: duration of invasive procedures >7 days [odds ratio (OR)=1.02], parenteral nutrition (OR=3.514), mechanical ventilation (OR=3.024), imipenem (OR=18.72), colistin (OR=5.645), probabilistic antibiotic therapy >4 days (OR=9.063) and neoplastic pathology (OR=5.727). Based on our results, it can be inferred that shortening the duration of stay in the resuscitation setting, implementing rational use of medical devices and optimizing antibiotic therapy could decrease the incidence of these infections.

Prognostic value of hemoglobin-to-red cell distribution width ratio in patients with cardiopulmonary resuscitation after out-of-hospital cardiac arrest

To investigate the prognostic value of hemoglobin-to-red cell distribution width ratio (HRR) in patients with cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA). A retrospective study was conducted. Patients aged ≥ 18 years with OHCA who were transferred to intensive care unit (ICU) after successful CPR from the emergency room of the First Affiliated Hospital of Zhengzhou University from August 2016 to February 2022 were enrolled. General clinical data, initial vital signs, acute physiology and chronic health evaluation II (APACHE II), Glasgow coma scale (GCS), first laboratory indicators after admission to ICU [including white blood cell count (WBC), red blood cell count (RBC), hemoglobin (Hb), pH value, lactic acid (Lac), 6-hour lactic acid clearance (LCR), red cell distribution width (RDW), HRR], length of ICU stay were collected. According to whether the patients died in hospital, the patients were divided into survival group and death group. Binary Logistic regression was used to analyze the independent factors influencing the prognosis of patients after CPR. Receiver operator characteristic curve (ROC curve) was drawn to analyze the predictive value of independent influencing factors for the prognosis of patients after CPR. A total of 122 patients were enrolled after OHCA CPR, of which 88 died in hospital, the in-hospital mortality was 72.13%. There were no significant differences in age, past medical history, initial vital signs and WBC in ICU between the two groups. Compared with the death group, the survival group had higher GCS score, RBC, Hb, pH value, 6-hour LCR, HRR, lower APACHE II score, Lac, RDW level, and longer length of ICU stay. Multivariate Logistic regression analysis showed that APACHE II score, GCS score, 6-hour LCR, HRR, length of ICU stay were independent factors influencing the prognosis of patients after CPR [APACHE II score: odds ratio (OR) = 0.784, 95% confidence interval (95%CI) was 0.683-0.901, P = 0.001; GCS score: OR = 1.390, 95%CI was 1.059-1.823, P = 0.018; 6-hour LCR: OR = 1.039, 95%CI was 1.015-1.064, P = 0.001; HRR: OR = 2.047, 95%CI was 1.383-3.029, P < 0.001; length of ICU stay: OR = 1.128, 95%CI was 1.046-1.216, P = 0.002]. ROC curve analysis showed that HRR, 6-hour LCR and APACHE II score could predict the prognosis of patients after CPR. The sensitivity was 85.3% and the specificity was 54.5% when the area under the ROC curve (AUC) of HRR was 0.731, and the cut-off value was 8.555. The sensitivity was 88.2% and the specificity was 46.6%, when the AUC of 6-hour LCR was 0.701, and the cut-off value was 28.947%. The sensitivity was 73.9% and the specificity was 79.4% when the AUC of APACHE II score was 0.848, the cut-off value was 22.000. The predictive value of the combination of HRR and 6-hour LCR was higher than that of a single index. The sensitivity was 79.3% and the specificity was 76.1%, when the AUC was 0.796, the cut-off value was 0.296. HRR, 6-hour LCR and APACHE II score have high prognostic value in patients with OHCA after CPR. HRR < 8.555, 6-hour LCR < 28.947% and APACHE II score > 22.000 indicated poor prognosis.

Evaluating the Need for Intensive Care Admission After Supraglottoplasty for Severe Laryngomalacia.

Postoperative airway concerns persist despite a low rate of post-supraglottoplasty complications for children with laryngomalacia. The objective of this study is to determine the factors associated with the need for intensive care unit (ICU) admission following supraglottoplasty. A 7-year retrospective cohort analysis was conducted between 2014 and 2021. A patient requiring ICU level of care was defined as the use of respiratory support such as intubation, positive pressure ventilation, high-flow nasal cannula, or multiple doses of nebulized epinephrine. About 134 medical charts were reviewed; 12 patients were excluded because of concurrent surgery. Age at the time of surgery was 2.8 (4.3) months (median [interquartile range]). About 33 (27.0%) ultimately required ICU-level care. Prematurity (odds ratio [OR] 13.8), neurological condition (OR ∞), American Society of Anesthesiology class 3-4 (OR 6.5), and younger age (OR 1.8) were more likely to require ICU admission. No patient above 10 months of age needed ICU monitoring. The use of respiratory support justifying ICU was known within the first 4 h after surgery for almost all (32/33, 97%) of these patients. 4/33 (12.1%) were kept intubated and the remaining needed non-invasive ventilation. Only one patient (1/122, 0.8%) was reintubated 12 h after surgery for progressive respiratory distress. Approximately a quarter of patients required ICU-level care after supraglottoplasty. For nearly all patients without comorbidities requiring ICU, this can be safely predicted within the first 4 h after surgery. Our data suggest that selected patients undergoing supraglottoplasty may be safely monitored outside of an ICU setting after an observation period in the post-anesthesia care unit. 4 Laryngoscope, 134:466-470, 2024.

A nonlinear relationship between the hemoglobin level and prognosis of elderly patients with sepsis: an analysis based on MIMIC-IV

To investigate the correlation of hemoglobin (Hb) level with prognosis of elderly patients diagnosed as sepsis. A retrospective cohort study was conducted. Information on the cases of elderly patients with sepsis in the Medical Information Mart for Intensive Care-IV (MIMIC-IV), including basic information, blood pressure, routine blood test results [the Hb level of a patient was defined as his/her maximum Hb level from 6 hours before admission to intensive care unit (ICU) and 24 hours after admission to ICU], blood biochemical indexes, coagulation function, vital signs, severity score and outcome indicators were extracted. The curves of Hb level vs. 28-day mortality risk were developed by using the restricted cubic spline model based on the Cox regression analysis. The patients were divided into four groups (Hb < 100 g/L, 100 g/L ≤ Hb < 130 g/L, 130 g/L ≤ Hb < 150 g/L, Hb ≥ 150 g/L groups) based on these curves. The outcome indicators of patients in each group were analyzed, and the 28-day Kaplan-Meier survival curve was drawn. Logistic regression model and Cox regression model were used to analyze the relationship between Hb level and 28-day mortality risk in different groups. A total of 7 473 elderly patients with sepsis were included. There was a "U" curve relationship between Hb levels within 24 hours after ICU admission and the risk of 28-day mortality in patients with sepsis. The patients with 100 g/L ≤ Hb < 130 g/L had a lower risk of 28-day mortality. When Hb level was less than 100 g/L, the risk of death decreased gradually with the increase of Hb level. When Hb level was ≥ 130 g/L, the risk of death gradually increased with the increase of Hb level. Multivariate Logistic regression analysis revealed that the mortality risks of patients with Hb < 100 g/L [odds ratio (OR) = 1.44, 95% confidence interval (95%CI) was 1.23-1.70, P < 0.001] and Hb ≥ 150 g/L (OR = 1.77, 95%CI was 1.26-2.49, P = 0.001) increased significantly in the model involving all confounding factors; the mortality risks of patients with 130 g/L ≤ Hb < 150 g/L increased, while the difference was not statistically significant (OR = 1.21, 95%CI was 0.99-1.48, P = 0.057). The multivariate Cox regression analysis suggested that the mortality risks of patients with Hb < 100 g/L [hazard ratio (HR) = 1.27, 95%CI was 1.12-1.44, P < 0.001] and Hb ≥ 150 g/L (HR = 1.49, 95%CI was 1.16-1.93, P = 0.002) increased significantly in the model involving all confounding factors; the mortality risks of patients with 130 g/L ≤ Hb < 150 g/L increased, while the difference was not statistically significant (HR = 1.17, 95%CI was 0.99-1.37, P = 0.053). Kaplan-Meier survival curve showed that the 28-day survival rate of elderly septic patients in 100 g/L ≤ Hb < 130 g/L group was significantly higher than that in Hb < 100 g/L, 130 g/L ≤ Hb < 150 g/L and Hb ≥ 150 g/L groups (85.26% vs. 77.33%, 79.81%, 74.33%; Log-Rank test: χ2 = 71.850, P < 0.001). Elderly patients with sepsis exhibited low mortality risk if their 100 g/L ≤ Hb < 130 g/L within 24 hours after admission to ICU, and both higher and lower Hb levels led to increased mortality risks.

Staphylococcus aureus Bacteremia in Pediatric Patients: Uncovering a Rural Health Challenge.

Staphylococcus aureus bacteremia poses significant risk for morbidity and mortality. This may be exacerbated in rural populations facing unique health challenges. To investigate factors influencing S. aureus bacteremia outcomes, we conducted a retrospective cohort study of children admitted to St. Louis Children's Hospital (SLCH) from 2011 to 2019. Exposures included rurality (defined by the Rural-Urban Continuum Code), Area Deprivation Index, and outside hospital (OSH) admission before SLCH admission. The primary outcome was treatment failure, a composite of 90-day all-cause mortality and hospital readmission. Of 251 patients, 69 (27%) were from rural areas; 28 (11%) were initially admitted to an OSH. Treatment failure occurred in 39 (16%) patients. Patients from rural areas were more likely to be infected with methicillin-resistant S. aureus (45%) vs urban children (29%; P = .02). Children initially admitted to an OSH, vs those presenting directly to SLCH, were more likely to require intensive care unit-level (ICU) care (57% vs 29%; P = .002), have an endovascular source of infection (32% vs 12%; P = .004), have a longer duration of illness before hospital presentation (4.1 vs 3.0 days; P = .04), and have delayed initiation of targeted antibiotic therapy (3.9 vs 2.6 days; P = .01). Multivariable analysis revealed rural residence (adjusted odds ratio [aOR], 2.3; 95% CI, 1.1-5.0), comorbidities (aOR, 2.9; 95% CI, 1.3-6.2), and ICU admission (aOR, 3.9; 95% CI, 1.9-8.3) as predictors of treatment failure. Children from rural areas face barriers to specialized health care. These challenges may contribute to severe illness and worse outcomes among children with S. aureus bacteremia.

Association of palliative care and hospital outcomes among solid tumour oncology inpatients

ObjectivesWe aimed to explore the association between receiving an inpatient palliative care consultation and hospital outcomes, including in-hospital death, intensive care unit (ICU) use, discharge to hospice, 30-day readmissions and...

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022.

Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

Physiotherapy services in intensive care. A workforce survey of Australia and New Zealand

BackgroundIn Australia and New Zealand, there are currently no recommendations to guide staffing levels for intensive care unit (ICU) physiotherapy services, and there is limited information about the current services provided. ObjectivesThe objective of this study was to document the profile of intensive care physiotherapy services currently offered in Australia and New Zealand. MethodsA binational survey was distributed to physiotherapists. The survey sought information on staffing and service profiles for weekday, weekend, and after-hour services including on-call and evening shifts. ResultsEighty-six sites completed the survey, with responses primarily from Level 3 (47/86, 55%) and public ICUs (74/86, 86%). For weekday services, the ratio of full-time equivalent physiotherapy staff allocated per bed was similar between all intensive care levels (0.11 [0.08–0.15], p = 0.421). Thirty respondents (35%) were satisfied with their staffing and reported higher levels of physiotherapy staff per bed (0.15 [0.1–0.2], p < 0.001). Most sites reported lower levels of staffing for weekend services (76/86, 88%), and many physiotherapists indicated that they were not satisfied with this service (55/86, 64%). Most Level 2, Level 3, and paediatric ICUs had a designated senior physiotherapist, with similar levels of senior physiotherapy staff allocated per bed between all ICU levels (0.05 [0.03–0.08], p = 0.844). Few sites reported dedicated staff attributed to intensive care education, research, tracheostomy service, or outreach roles. On-call physiotherapy services were available in 49 of 86 (57%) hospitals surveyed; however, utilisation of the service by ICUs was mainly reported to be less than once per month (19/49, 39%). ConclusionsPhysiotherapy staffing ratios were similar across different ICU levels. While weekend services are available for most ICUs, staffing levels are reduced. Higher staffing ratios were associated with higher levels of satisfaction to complete professional roles and responsibilities.

1087. COVID-19 in Solid Organ Transplant Recipients: A Single Transplant Center Experience

Abstract Background COVID-19 disease became a global health care crisis and was declared pandemic by WHO in March 2020. Some studies have indicated that Solid Organ Transplant (SOT) patients may have increased morbidity and mortality while others showed no difference. Our study aims to investigate patients’ characteristics, disease course, management of COVID-19 and outcomes in our SOT patient population. Methods We conducted a retrospective cohort study of all consecutive SOT recipients who were admitted to our transplant center from March 2020 to April 2021 with COVID-19 infection. Data was collected from the electronic medical records after receiving Institutional Review Board approval. Table 1Study Population Demographics Figure 1 Age and Gender distribution of the study population Results A total of 135 patients met inclusion criteria. Average age at the time of COVID-19 diagnosis was 56.38±12.93 years. Majority of the patients (54%) were kidney transplant recipients. Out of the total, 28% of the patients required supplemental oxygen and 14% required intensive care unit (ICU) care. A total of 12 patients (9%) required intubation and mechanical ventilation. 21% of the patients were treated with Remdesivir and 30% met criteria for the use of corticosteroids. Unfortunately, 11 patients (8%) of the patients died from COVID-19 infection and its complications. Of those 11 patients 5 were treated with Remdesivir and 10 were treated Corticosteroids. None of the patients met the criteria for ECMO (Extra Corporeal Membrane Oxygenation). Figure 2Study Population Distribution of the Types of Transplants at time of COVID-19 infection Figure 3 Outcomes - Admission to ICU and Mortality Figure 4 COVID-19 Therapies and Outcomes in the SOT Recipients Conclusion Our study showed a higher mortality rate in SOT patients compared to general population. Treatment with Remdesivir and Corticosteroids improved the overall mortality rate but had no benefit in patients with critical illness requiring ICU level care. COVID vaccination significantly improved the outcome, and the major limitation of the study was COVID vaccination information was not included since the study was initiated prior to introduction of vaccines. More studies with larger sample size and vaccine data need to be conducted to accurately determine the outcome of COVID-19 infection in this patient population. Disclosures All Authors: No reported disclosures.