Non-intensive Care Unit Setting Research Articles

SQuID (subcutaneous insulin in diabetic ketoacidosis): Clinician acceptability.

We previously implemented the SQuID protocol (subcutaneous insulin in diabetic ketoacidosis [DKA]) demonstrating safe, effective treatment of low- to moderate-severity DKA in a non-intensive care unit setting. Since success and sustainability of interventions rely on staff buy-in, we assessed acceptability of SQuID among emergency department (ED) and inpatient clinicians. We conducted a cross-sectional study in an urban academic hospital (March 2023-November 2023), surveying ED nurses (RNs) and physicians (MDs) and floor RNs and MDs treating patients on SQuID via emailed survey links. Clinicians could only take the survey once. We used Sekhon's Theoretical Framework of Acceptability, validated for staff acceptability of a new intervention, assessing eight domains with 5-point Likert responses. Clinicians were asked about prior experience with SQuID, and we assessed ED MD and RN preference (SQuID vs. intravenous [IV] insulin). Surveys included free-text boxes for comments. We present descriptive statistics including proportions with 95% confidence interval and medians with interquartile ranges (IQRs) and conducted thematic analysis of free-text comments. Our overall response rate (107/133) was 80% (34/42 ED RNs, 13/16 floor RNs, 47/57 ED MDs, 13/17 floor MDs), with first-time users of SQuID ranging from 7.7% (hospitalist MDs) to 35.3% (ED RNs) of participants. ED clinicians preferred SQuID over IV insulin (67% vs. 12%, 21% no preference). Acceptability was high across all domains and clinician types (median 4, IQR 4-5). Overall percentage of positive responses (4s and 5s) across domains was 92% (ED RNs [89%], floor RNs [89%], ED MDs [97%], floor MDs [87%]). We identified several themes among participant comments. Acceptability was high across clinician types; 65% of ED clinicians preferred SQuID to IV insulin. Clinicians liked SQuID (affective attitude), found it easy to use (burden), were confident in its use (self-efficacy), felt that it improved outcomes (perceived effectiveness), found that it was fair to patients (ethicality), found that it made sense (intervention coherence), and found that it did not interfere with other activities (opportunity cost).

Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review.

International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice. We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication. Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded. we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including 'delirium' and 'antipsychotic'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool. descriptive data were extracted in Covidence and synthesised in Microsoft Excel. Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16). in 18 studies, participants' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg). The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.

Delirium in the United States: Results From the 2023 Cross-Sectional World Delirium Awareness Day Prevalence Study

Delirium is an acute brain dysfunction associated with an increased risk of mortality and future dementia. To describe the prevalence of clinically documented delirium in the United States on World Delirium Awareness Day2023. This is a sub-analysis of a prospective, cross-sectional, online, international survey. All health care settings were eligible, with the exception of operating rooms and outpatient clinics. Health care clinicians, administrators, and researchers completed the survey. The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. and 8:00 p.m. on March 15, 2023. Secondary outcomes were related to health care delivery. Descriptive statistics are reported. Differences between unit types (non-intensive care unit vs intensive care unit) were examined for all outcomes. Ninety-one hospital units reported on 1318/1213 patients. The prevalence of clinically documented delirium was 16.4% (n= 216/1318) at 8:00 a.m. and 17.9% (n= 217/1213) at 8:00 p.m. (P=0.316) and significantly differed between age groups, reported discipline, unit, and hospital types. Significant differences were identified between non-intensive care unit and intensive care unit settings in the use of delirium-related protocols, nonpharmacologic and pharmacologic management, educational processes, and barriers to evidence-based delirium care. To our knowledge, this is the first epidemiologic survey of clinically documented delirium across two time points in the United States. Delirium remains a significant burden and challenge for health care systems. The high percentage of units using delirium management protocols suggests administrator and clinician awareness of evidence-based strategies for its detection and mitigation. We provide recommendations for future studies and quality improvement projects to improve clinical recognition and management of delirium.

Pediatric trauma patients with isolated grade III blunt splenic injuries may be safely managed without intensive care unit admission

BackgroundNon-operative management is the standard of care for pediatric blunt splenic injury. The American Pediatric Surgical Association recommends intensive care unit monitoring only for grade IV/V blunt splenic injury; however, variation remains regarding this practice. We hypothesized that pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to a non-intensive care unit setting would have similar outcomes to those admitted to the intensive care unit. MethodsThe 2017 to 2019 Trauma Quality Improvement Program database was queried for blunt pediatric trauma patients (≤16 years) with near-isolated grade III blunt splenic injuries. Patients with systolic blood pressure <90 mmHg or heart rate >90 were excluded. Pediatric trauma patients admitted to the intensive care unit were compared to non-intensive care unit admissions. The primary outcome was splenectomy. Bivariate analyses were performed. ResultsOf 461 pediatric trauma patients with near-isolated grade III blunt splenic injuries, 186 (40.3%) were admitted to the intensive care unit. Intensive care unit patients were older than their non-intensive care unit counterparts (15 vs 14 years, P = .03). Intensive care unit and non-intensive care unit patients had a similar rate of splenectomy (0.5% vs 0.7%, P = .80) and time to surgery (19.7 vs 19.8 hours, P = .98). Patients admitted to the intensive care unit had a longer length of stay (4 vs 3 days, P < .001). There were no significant complications or deaths in either group. ConclusionThis national analysis demonstrated that hemodynamically stable pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to the floor or intensive care unit had a similar rate of splenectomy without complications or deaths. This aligns with American Pediatric Surgical Association recommendations that pediatric trauma patients with grade III blunt splenic injuries be managed in non-intensive care unit settings. Widespread adoption is warranted and should lead to decreased healthcare expenditures.

Determinants of delirium in elderly in-patients in a general ward setting in a teaching hospital: A case control study

Background: There is a dearth of research on risk factors of delirium among elderly inpatients in nonintensive low resource settings. Aim: To determine the risk factors of delirium in elderly inpatients in a nonintensive care unit setting. Materials and Methods: Sixty two elderly patients with delirium (cases) and 62 patients without delirium (controls) were administered a semi-structured proforma with socio-demographic variables and putative predisposing and precipitating risk factors and the Vellore screening instrument for dementia. Results: On univariate analysis, factors such as past cognitive impairment, history of nocturnal confusion and delirium, diminished daily living activities, severe medical illness, history of psychiatric illness, presence of dementia, infection, fever above 1000F, abnormal electrolytes abnormal RFT, leukocytes in urine, hypoxia, anticholinergics and benzodiazepines, emergency admission, use of physical restraints, bladder catheterization, more than routine investigations, intensive care unit admission, surgery, and duration of hospital stay more than 10 days were found to be significantly associated with delirium. On multivariate analysis with binary logistic regression, bladder catheterization (odds ratio [OR] = 13.85; confidence interval [CI] = 1.44-133.14), abnormal electrolytes (OR = 5.12; CI = 1.11-23.69), and hypoxia (OR = 75.52; CI = 4.64-1.134E3) were detected to be independently associated with delirium. Conclusion: Acute modifiable rather than long-term factors were risk factors for delirium among the elderly. An awareness of modifiable risk factors has the potential of developing targeted interventions for the early mitigation of delirium.

Clinical Features and Liver Function Tests in Non-ICU Hospitalized Patients with COVID-19 in University of Phayao Hospital

Background: SARS-CoV-2 has had a variety of symptoms, from mild to acute respiratory distress syndrome or multiple organ failure. Objective: To determine the epidemiological and clinical features of patients with COVID-19 who were admitted to non-intensive care unit (non-ICU) settings and to compare the results of liver function test (LFT) among different groups of non-ICU hospitalized patients with COVID-19. Materials and Methods: The retrospective cross-sectional study was conducted at the University of Phayao Hospital, Thailand. Patients diagnosed with COVID-19 and admitted to non-ICU wards between November 2021 and March 2022 were included. Descriptive data were analyzed using mean ± standard deviation or median (interquartile range), Pearson’s chi-square test, and analysis of variance (ANOVA). Results: Three hundred ninety-nine patients were included in the present study, with the median age of 30.2 years. Fifty-five percent of the patients were female, 45.9% had normal BMI, and 89% had no comorbidities. Common symptoms were non-productive cough in 62.4%, sore throat in 52.9%, and fever in 37.3%. Twenty-one patients (5.3%) were classified as Group 1, 311 patients (77.9%) were in Group 2, and 67 patients (16.8%) were in Group 3, according to the Ministry of Public Health of Thailand guidelines. Thirty-five percent of patients had LFT abnormalities on admission. Nine patients (2.2%) had chest X-ray abnormalities, of which five were found at the time of admission, and most had normal LFTs. Four patients who developed pulmonary infiltration during their hospital stay also had abnormal LFT afterward. No patients were transferred to the ICU, required vasopressors, needed mechanical ventilation during hospitalization, or died. Conclusion: The authors’ study provides clinical and LFT data on hospitalized, non-ICU COVID-19 patients in a single university hospital. These results also represent epidemiological value and guidance for treatment in the current endemic area. Keywords: COVID-19; Liver function test; Non-ICU hospitalized patients

Association of language concordance and restraint use in adults receiving mechanical ventilation.

Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes. We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect). Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common. We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.

Infectious Diseases: What You May Have Missed in 2022.

In 2022, COVID-19 remained the infectious disease at the top of most internal medicine physicians' minds. However, it was not the only infectious disease that was the topic of clinically relevant research that year. This article highlights some important infectious disease evidence unrelated to COVID-19 that was published in 2022. The literature was screened for sound new evidence relevant to internal medicine specialists and subspecialists whose focus of practice is not infectious diseases. The publications highlighted relate to various organisms in different patient populations. One article provides insight into the role of Helicobacter pylori eradication in the treatment of functional dyspepsia. The descriptive epidemiology of bacterial (Staphylococcus aureus) and viral (mpox) infections are the focus of 2 other articles. Several articles address the management of resistant and difficult-to-treat infections: multidrug-resistant gram-negative infections, resistant HIV-1, rifampin-resistant tuberculosis, cryptococcal meningitis, and invasive fungal infection in the setting of neutropenia. Another article provides data on effective HIV preexposure prophylaxis in women, an understudied population. Finally, given the urgent need to reduce inappropriate use of antibiotics, an article on antibiotic stewardship for hospitalized patients with presumed sepsis in a non-intensive care unit setting is also included.

The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics.

Studies using fast-acting subcutaneous (SQ) insulin analogs in diabetic ketoacidosis (DKA) have demonstrated efficacy, safety, and cost-effectiveness, allowing treatment of mild-to-moderate (MTM)-severity DKA patients in non-intensive care unit (ICU) settings. However, emergency department (ED)-based studies are few, with limited exploration of impacts on operational metrics. We implemented the SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) protocol for adults with MTM-severity DKA in an urban academic ED, collecting data from August 1, 2021, to February 28, 2022. We examined fidelity (frequency of required q2h glucose checks), safety (proportion of patients administered rescue dextrose for hypoglycemia), and ED length of stay (EDLOS) for the SQuID cohort compared to patients (non-ICU) treated with a traditional insulin infusion. We also examined ICU admission rate among MTM-severity DKA patients after introduction of SQuID to two historical control periods (pre-intervention and pre-COVID). We used Mann-Whitney U to test for differences in EDLOS distributions, bootstrapped (n= 1000) confidence intervals (CIs) for EDLOS median differences, and the two-sample z-test for differences in ICU admissions. We identified 177 MTM-severity DKA patients in the study period (78 SQuID, 99 traditional cohort) and 163 preintervention and 161 pre-COVID historical control patients. Fidelity to the SQuID pathway was good, with glucose checks exceeding the q2-h requirement. We found no difference in the proportion of rescue dextrose administration compared to the traditional pathway. We observed significant reductions in median EDLOS for the SQuID cohort compared to the traditional cohort during the study period (-3.0, 95% CI -8.5 to -1.4), the preintervention period (-1.4, 95% CI -3.1 to -0.1), and the pre-COVID control period (-3.6, 95% CI -7.5 to -1.8). In this single-center study at an academic ED, treatment of patients with MTM-severity DKA with a SQ insulin protocol was effective, demonstrated equivalent safety, and reduced ED length of stay.

LBSUN207 Efficacy And Safety Of Degludec U100 Versus Glargine U300 For The Hospital Management Of Patients With Type 2 Diabetes: A Prospective, Open-label, Non-inferiority Randomized Controlled Trial

Abstract Aims No head-to-head comparisons of two ultra-long acting insulins, degludec-100 and glargine-300, have been reported in the inpatient setting. We compared the efficacy and safety of these two insulins for the hospital management of patients with type 2 diabetes (T2D). Methods This target-to-treat, randomized controlled trial enrolled patients with T2D admitted for coronary artery bypass graft surgery (CABG). On the day of transition (day 2 of surgery) from intravenous insulin infusion to multiple subcutaneous insulin injections, patients were randomly assigned (1: 1) to receive a basal-bolus regimen using either degludec-100 or glargine-300 as basal and glulisine as bolus before meals. Insulin was adjusted daily to maintain a fasting blood glucose (BG) &amp;lt;140 mg/dL and pre-meal BG &amp;lt;180, while avoiding hypoglycemia &amp;lt;70 mg/dL. The primary endpoint was non-inferiority in mean differences between groups in their daily BG concentrations measured during the duration of the hospital stay and a week post-discharge, up to 12 days (point-of-care measurements, pre-breakfast, pre-lunch, pre-dinner and nighttime [0300 hours]: non-inferiority was deemed a difference &amp;lt;18 mg/dL). The major safety outcome was the occurrence of hypoglycemia. Secondary outcome measures included mean differences between groups in their daily BG concentrations, time in range (TIR, %), time below range (TBR, %), and time above range(TAR, %), as assessed by continuous glucose monitoring system (CGMS, n = 142). Results Between October 12, 2021, and February 10, 2022, 324 consecutive patients with T2D undergoing CABG were screened, 239 patients were randomly assigned to treatment; 122 to degludec-100 group and 117 to glargine-300 group. The mean daily BG concentration in the degludec-100 group (157 mg/dL [SD 25]) was not inferior to that in the glargine-300 group (162 mg/dL [SD 24]), with a mean BG difference of -5 mg/dL (95% CI, -11 to 2, p = 0.18). There were no differences between degludec-100 group and glargine-300 group in mean percentage of readings within target BG of 70-180 mg/dL (74% ± 29% vs. 73% ± 30%, p = 0.19), daily basal insulin dose (19 ± 8 vs. 21 ± 9 units/day, p = 0.13), length of stay in hospital (median [IQR]: 9 [8-11] vs. 9 [8-11] days, p = 0.51), or hospital complications (21.3% vs. 21.4%, p = 0.99). There were no differences in the proportion of patients with BG &amp;lt;70 mg/dL (15.6% vs. 23.1%, p = 0.14) or &amp;lt;54 mg/dL (1.6% vs. 4.3%, p = 0.226) between degludec-100 and glargine-300 groups. There was no difference between groups in mean daily BG concentrations (141 ± 26 vs. 142 ± 28 mg/dL, p = 0.88), TIR (72. 0% vs. 72.9%, p = 0.71), TBR (5.9% vs. 5.2%, p = 0.50) and TAR (22. 0% vs. 21.8%, 0.93) as assessed by CGMS. Conclusions Treatment with degludec-100 as a basal insulin is as effective and safe as glargine-300 for the hospital management of patients with T2D admitted to cardiac surgery service in the non-intensive care unit setting. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Patents experiences of in-hospital telemetry monitoring

Abstract Background Telemetry monitoring is a cornerstone of care in in-hospital arrhythmia monitoring. Annually, a large number of patients experience arrhythmias that need to be monitored and treated during hospital stay. However, studies focusing on patients' experiences of telemetry monitoring are scarce. Purpose To explore and describe adult patients' experiences of in-hospital monitoring in a non-intensive care unit setting. Methods In-depth interviews with an inductive, explorative and descriptive design were performed before hospital discharge at two university hospitals in Norway. Twenty patients were purposefully selected. Inclusion criteria were; monitored for more than 72 hours, with at least one serious arrhythmia registered. A qualitative content analysis according to Graneheim and Lundman was performed revealing categories at a manifest level. Findings Patients were 25–83 years (mean 62), and had spent an average of 9 days on telemetry (3–14). Patients were monitored due to primary arrhythmia (9), STEMI (2), syncope (2), TAVI (1), acute heart failure (1), heart transplant (1), GUCH (1) and non-cardiac causes (3). Four main categories were revealed from the analysis. Firstly, patients' experienced to receive limited information related to the purpose and results of the monitoring. Communication with the staff and immediate response to arrhythmias were important factors to feel safe and taken care of during hospital stay. Secondly, patients experienced the monitoring system to be troublesome. The device and the wires attached made it challenging to maintain adequate hygiene. Patients also experienced sleeping problems related to both wires and disturbing alarms, and described pain in the neck due to the weight of the telemetry unit. Thirdly, patients' experienced a restricted range of activity. Patients experienced the restricted radius of movement as a feeling of security, even though patients also described uncomfortable feelings like “wearing an ankle brace”. Fourthly, patients' experienced uncertainty at hospital discharge as the telemetry monitoring was discontinued, especially if they still experienced arrhythmias. Conclusion The information provided to patients on telemetry monitoring is poor and there is need for a better system to carry the telemetry in order to ease mobilisation and facilitate good sleep. Patients need to be informed about the results of the telemetry monitoring, to help them to be familiar with their arrhytmia, and increase the experience of security after discharge. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): 1 Department of Health and Social Sciences at Western Norway University of Applied Sciences, Norway2 Department of Heart Disease, Haukeland University Hospital, Norway

Management of Glucocorticoid-Induced Hyperglycemia.

Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.

Adoption of the use of a reflective blanket for passive re-warming of the stable mildly hypothermic patient to reduce unnecessary ICU admissions: A pilot study

Background and objective: In adult inpatients, thermoregulation is important to support vital functions. Occasionally, due to procedures or benign clinical conditions, such as hypoglycemia, autonomic instability, brain injury, paraplegia, autonomic dysreflexia, and septic shock, patients’ body temperature falls below 35°C and thus, requires intervention. Due to the floor nursing constraints of hourly monitoring of forced air re-warming, these active warming techniques often lead to clinically unnecessary admissions to intensive care units and utilization of scarce and costly resources. The purpose of this pilot study was to explore passive re-warming with alternative technologies to avoid unnecessary admissions to the intensive care unit.Methods: A pilot study based on a sample of seventeen patients was conducted to assess the adoption and associated outcome of the use of the reflective blanket. Intervention: Application of a reflective blanket to patients who were mildly hypothermic, yet clinically stable, was explored as an effective mechanism to re-warm these patients in the non-intensive care unit setting. Results: The investigation based on the use of a reflective blanket on a sample of seventeen hypothermic patients had a success rate of 0.7059 (70.59%).Conclusions: We conclude that the use of a reflective blanket is an effective and safe passive rewarming mechanism that leads to avoidance of unnecessary intensive care unit admissions. This leads to both cost reductions to patients and appropriate use of ICU resources.

Cost analysis of hospitals performing continuous albuterol in non-intensive care settings

Objective To compare hospital costs and resource utilization for pediatric asthma admissions based on the hospitals’ availability of continuous albuterol aerosolization administration (CAA) in non-intensive care unit (ICU) settings. Methods We conducted a retrospective cohort study of children ages 2-17 years admitted in 2019 with a principal diagnosis of asthma using the Pediatric Health Information System. Hospitals and hospitalizations were categorized based on location of CAA administration, ICU-only versus general inpatient floors. Hospitals preforming CAA in an intermediate care unit were excluded. We calculated total cost, standardized unit costs and rates of interventions. Groups were compared using Chi-Square, t-test and Wilcoxon rank-sum test as indicated. A log linear mixed model was created to evaluate potential confounders. Results Twenty-one hospitals (7084 hospitalizations) allowed CAA on the floor. Twenty-four hospitals (6100 hospitalizations) allowed CAA in the ICU-only. Median total cost was $4639 (Interquartile Range (IQR) $3060–$7512) for the floor group and $5478 (IQR $3444–$8539) for the ICU-only group (p < 0.001) (mean cost difference of $775 per patient). Hospitalization costs were $4,726,829 (95% CI $3,459,920–$5,993,860) greater for the children treated at hospitals restricting CAA to the ICU. We observed higher standardized laboratory, imaging, clinical and other unit costs, along with higher use of interventions in the ICU-only group. After adjustment, we found that ICU stay and hospital LOS were the main drivers of cost difference between the groups. Conclusions There was cost savings and decreased resource utilization for hospitals that performed CAA on the floor. Further studies exploring variations in asthma management are warranted.

A Survey of Hospital Pharmacy Guidelines for the Administration of 3% Sodium Chloride in Children.

Three percent sodium chloride (3% NaCl) is the treatment of choice for symptomatic hyponatremia. A barrier to the use of 3% NaCl is the perceived risk of both local infusion reactions and neurologic complications from overcorrection. We examine whether children’s hospital pharmacies have policies or practice guidelines for the administration of 3% NaCl and whether these pharmacies have restrictions on the administration of 3% NaCl in terms of rate, route, volume and setting. An Internet survey was distributed to the pharmacy directors of 43 children’s hospitals participating in the Children’s Hospital Association (CHA) network. The response rate was 65% (28/43). Ninety-three percent (26/28) of pharmacy directors reported a restriction for the administration of 3% NaCl, with 57% restricting its use through a peripheral vein or in a non-intensive care unit setting, 68% restricting the rate of administration and 54% restricting the volume of administration. Seventy-one percent (20/28) reported having written policy or practice guidelines. Only 32% of hospital pharmacies allowed 3% NaCl to be administered through a peripheral IV in a non-intensive care unit setting. The majority of children’s hospital pharmacies have restrictions on the administration of 3% NaCl. These restrictions could prevent the timely administration of 3% NaCl in children with symptomatic hyponatremia.

Modifiable risk factors of ventilator-associated pneumonia in non-intensive care unit versus intensive care unit.

Ventilator-associated pneumonia patients are treated in non-intensive care units because of a shortage of intensive care unit beds in Thailand. Our objective was to assess whether the type of unit and medications prescribed to the patient were associated with ventilator‑associated pneumonia and multidrug resistant ventilator‑associated pneumonia. A matched case-control study nested in a prospective cohort of mechanical ventilation adult patients in a medical-surgical intensive care unit and five non-intensive care units from March 1 through October 31, 2013. The controls were randomly selected 1:1 with cases and matched based on duration and start date of mechanical ventilation. 248 ventilator-associated pneumonia and control patients were analyzed. The most common bacteria were multidrug resistant Acinetobacter baumannii (82.4%). Compared with patients in the intensive care unit, those in the neurosurgical/surgical non-intensive care units were at higher risk (p = 0.278). Proton pump inhibitor was a risk factor (p = 0.011), but antibiotic was a protective factor (p = 0.054). Broad spectrum antibiotic was a risk factor (p < 0.001) for multidrug resistant ventilator-associated pneumonia. Post-surgical and neurosurgical patients treated in non-intensive care unit settings were at the highest risk of ventilator-associated pneumonia. Our findings suggest that alternative using proton pump inhibitors should be considered based on the risk-benefit of using this medication. In addition, careful stewardship of antibiotic use should be warranted to prevent multidrug resistant ventilator-associated pneumonia.

Convalescent Plasma Therapy in Critically Ill COVID-19 Patients: An Open Label Trial.

ObjectivesThe novel severe acute respiratory syndrome coronavirus 2 pandemic continues to spread globally without an effective treatment. In search of the cure, convalescent plasma (CP) containing protective antibodies from survivors of coronavirus disease 2019 (COVID-19) infection has shown potential benefit in a non-intensive care unit setting. We sought to evaluate the effectiveness of CP therapy for patients with COVID-19 on mechanical ventilation (MV) and/or acute respiratory distress syndrome (ARDS).MethodsWe conducted an open-label trial in a single center, Royal Hospital, in Oman. The study was conducted from 17 April to 20 June 2020. The trial included 94 participants with laboratory-confirmed COVID-19. The primary outcomes included extubation rates, discharges from the hospital and overall mortality, while secondary outcomes were the length of stay and improvement in respiratory and laboratory parameters. Analyses were performed using univariate statistics.ResultsThe overall mean age of the cohort was 50.0±15.0 years, and 90.4% (n = 85) were males. A total of 77.7% (n = 73) of patients received CP. Those on CP were associated with a higher extubation rate (35.6% vs. 76.2%; p < 0.001), higher extubation/home discharges rate (64.4% vs. 23.8%; p =0.001), and tendency towards lower overall mortality (19.2% vs. 28.6%; p =0.354; study power = 11.0%) when compared to COVID-19 patients that did not receive CP.ConclusionsCP was associated with higher extubation/home discharges and a tendency towards lower overall mortality when compared to those that did not receive CP in COVID-19 patients on MV or in those with ARDS. Further studies are warranted to corroborate our findings.

Comparison of various basal insulin dose adjustments for inpatients while unable to eat.

Background The American Diabetes Association recommends basal insulin or basal plus correctional insulin regimen for non-critically ill patients with type 2 diabetes mellitus unable to eat. There is limited evidence available examining ideal basal insulin dose reductions in this patient population. Aim This study aimed to determine the percent reduction of maintenance basal insulin that would provide the least hypoglycemic incidence in patients with type 2 diabetes mellitus in the non-intensive care unit setting. Methods This retrospective cohort study evaluated adult patients with type 2 diabetes mellitus prescribed outpatient basal insulin with a minimum unable to eat status of two hours. Patients were divided into four groups; <25%, 25-50%, 51-75%, > 75% of basal insulin administered compared to home dose. The primary endpoint was the incidence of hypoglycemia while unable to eat. Secondary endpoints included incidence of hyperglycemia, severe hypoglycemia, median daily blood glucose and hospital length of stay. Results A total of 173 patients were included. The primary outcome of hypoglycemia (5.9% vs. 8.8% vs. 14.3% vs. 12.3%; P = 0.578) was similar in all groups. There were no differences in hyperglycemia (P = 0.0701), severe hypoglycemia (P = 0.578) and median daily blood glucose (P = 0.428). Patients receiving 25-50%of home basal insulin had the longest unable to eat duration (11.5h; P = 0.026); however, this was not statistically significant when adjusted using the Bonferroni correction for multiple tests. Conclusions No differences were observed in hypoglycemic events for patients unable to eat receiving various basal insulin dose reductions.

Feasibility and Effectiveness of Norepinephrine Outside the Intensive Care Setting for Treatment of Hepatorenal Syndrome.

Vasoconstrictors are the treatment of choice for hepatorenal syndrome (HRS). We evaluate the real-life effectiveness of a sequential vasoconstrictor regimen of midodrine-octreotide followed by norepinephrine in a nonintensive care unit (non-ICU) setting in the United States, where terlipressin is not available. The diagnosis of HRS and definitions of response to therapy were based on 2015 guidelines from the International Club of Ascites. In adult patients with HRS without partial or full response to oral midodrine and subcutaneous octreotide, norepinephrine was administered at a starting dose of 5mcg/minute, with a goal to achieve a mean arterial pressure (MAP) of 10mm Hg above baseline. We assessed predictors of response and treatment outcomes. A total of 61 patients were administered midodrine and octreotide for the treatment of HRS, with a 28% response rate. The median MELD-Na (Model for End-Stage Liver Disease-sodium) score was 30 (interquartile range [IQR] 24-35). Responders were more likely to have alcohol-related liver disease and lower Acute-on-Chronic Liver Failure (ACLF) grade. Of the nonresponders, 20 were then administered norepinephrine, of whom 45% achieved full or partial response. Achieving an MAP increase of ≥10mm Hg was associated with a greater probability of response. Patients who responded to norepinephrine experienced improved transplant-free survival at 90days (88% versus 27%; P=0.02); 5 of 20 patients experienced norepinephrine treatment-related adverse events, namely arrhythmias. Norepinephrine can be effectively used in a non-ICU setting as rescue therapy in patients who have not responded to midodrine and octreotide. Based on these data, we propose a practical stepwise algorithm for vasoconstrictor therapy to manage HRS in situations where terlipressin is not an option.

Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission

Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.