Normal Wards Research Articles

"I don't want hear about that": Treatment wishes/preferences of elderly patients regarding possible treatment goals in acute life-threatening illness or acute organ failure

Abstract Background In many people with acutely life-threatening illnesses, the will to undergo treatment is not known with sufficient precision. It is often unclear whether the person concerned would have consented to life-sustaining measures or would have preferred to die with palliative care. This applies in particular to the vulnerable group of elderly, chronically ill/fragile people. It is not uncommon for people to reject the risks/burdens of medical treatment, even if there is a chance of success. On the other hand, there are many people who fight to continue living, even if this can be associated with great burdens and the outcome is rather uncertain. Aim of the study is to determine the characteristics of cardiologic patients who refuse to discuss treatment wishes/preferences in case of acute emergencies, temporary (e.g. in the context of intensive care unit (ICU) treatment), or permanent (vegetative state) inability to consent. Methods Prospective, questionnaire-based cross-sectional study including Hospital Anxiety and Depression Scale (HADS) and assessment of quality of life using the 12-item Short Form Health Survey (SF-12) on normal cardiology wards. Results 455 cardiologic patients were interviewed (mean age 71.2 ± 12.9 years, 39.6% female), 76.1% had moderate-severe concomitant diseases according to the Carlsson Comorbidity Index (4.3 ± 2.4 points) (see Table I). 23.5 % of respondents did not wish to address the above-mentioned question, they were significantly older (74.6 ± 13.1 vs. 69.9 ± 12.8 years; p=0.0009), had more comorbidities, were less likely to have a high level of education (university degree: 13.0 % vs. 30.6 %; p=0.0021) and were less likely to be employed (11.7 % vs. 25.8 %; p=0.0026). Furthermore, these patients live alone more frequently (45.8% vs. 30.6%; p=0.0048) and are less likely to live in a partnership (52.0% vs. 68.0%; p=0.0043). Refusal of an advance directive was also more common (22.5% vs. 10.7%; p=0.05), quality of life was impaired (42.4 ± 9.8 vs. 45.9 ± 10.5 points; p=0.0022), and the HADS-score levels were higher (15.6 ± 7.3 vs. 12.7 ± 7.8 points; p=0.0007). Conclusions A relevant proportion of our patients refuse to discuss treatment wishes/preferences in case of acute emergencies, temporary or permanent inability to consent. Paradoxically, these were patients for whom it would make particular sense (older, sicker, and more socially isolated patients). Those patients are also prone to anxiety and depression, and have a reduced quality of life.

Investigating the relationship between lymphocyte cells apoptosis and DNA damage and oxidative stress and therapeutic and clinical outcomes of COVID-19 elderly patients

BackgroundWhile COVID-19 has been controlled and deaths have decreased, the long-term consequences of COVID-19 remain a challenge we face today. This study was conducted to determine the relationship between the apoptosis of lymphocyte cells with DNA damage and oxidative stress and the therapeutic and clinical outcomes of elderly patients with COVID-19.MethodsThis study was conducted from April 2020 to May 2021 (the period of severe attacks of the epidemic peak of COVID-19) and September 2022 (the post-COVID-19 period). The study groups included elderly patients with COVID-19 hospitalized in the ICU and normal wards of the hospital as well as elderly patients with influenza. A polymerase chain reaction was used to check the validity of the studied diseases. The Annexin V/Propidium Iodide method was used to evaluate the level of apoptosis. Genotoxic effects and DNA damage were assessed by the comet assay method. Total antioxidant status (TAS), total oxidant status (TOS), and myeloperoxidase activity (MPO) were measured by photometric methods.ResultsThe highest level of apoptosis in peripheral blood lymphocytes and the highest level of DNA damage were observed at both times in the intubated-ICU and non-intubated-ICU groups. In all groups, there was a significant increase in peripheral blood lymphocyte apoptosis levels and DNA damage levels compared to the healthy control group (p < 0.01). The level of apoptosis and DNA damage decreased significantly in the post-COVID-19 period (p < 0.01). In the investigation of oxidative stress biomarkers, the oxidative stress index, including TOS and MPO levels, increased in patients (p < 0.01), and the TAS level decreased (p < 0.01).ConclusionIt shows that the apoptosis of lymphocyte cells, DNA damage, and oxidative stress can be effective in prognostic decisions and is a suitable predictor for diagnosing the condition of patients with viral infections such as COVID-19 and influenza.

The current state of intensive care unit discharge practices - Results of an international survey study.

Increasing pressure on limited intensive care capacities often requires a subjective assessment of a patient's discharge readiness in the absence of established Admission, Discharge, and Transfer (ADT) guidelines. To avoid suboptimal care transitions, it is important to define clear guidelines for the admission and discharge of intensive care patients and to optimize transfer processes between the intensive care unit (ICU) and lower care levels. To achieve these goals, structured insights into usual ICU discharge and transfer practices are essential. This study aimed to generate these insights by focusing on involved stakeholders, established processes, discharge criteria and tools, relevant performance metrics, and current barriers to a timely and safe discharge. In 2022, a structured, web-based, anonymous cross-sectional survey was conducted, aimed at practicing ICU physicians, nurses, and bed coordinators. The survey consisted of 29 questions (open, closed, multiple choice, and scales) that were divided into thematic blocks. The study was supported by several national and international societies for intensive care medicine and nursing. A total of 219 participants from 40 countries (105 from Germany) participated in the survey. An overload of acute care resources with ~90% capacity utilization in the ICU and the general ward (GW) leads to not only premature but also delayed patient transfers due to a lack of available ward and intermediate care (IMC) beds. After multidisciplinary rounds within the intensive care team, the ICU clinician on duty usually makes the final transfer decision, while one-third of the panel coordinates discharge decisions across departmental boundaries. By the end of the COVID-19 pandemic, half of the hospitals had implemented ADT policies. Among these hospitals, nearly one-third of the hospitals had specific transfer criteria established, consisting primarily of vital signs and laboratory data, patient status and autonomy, and organization-specific criteria. Liaison nurses were less common but were ranked right after the required IMC capacities to bridge the care gap between the ICU and normal wards. In this study, 80% of the participants suggested that transfer planning would be easier if there was good transparency regarding the capacity utilization of lower care levels, a standardized transfer process, and improved interdisciplinary communication. To improve care transitions, transfer processes should be managed proactively across departments, and efforts should be made to identify and address care gaps.

Utilisation of artificial intelligence to predict early readmission to the cardiac intensive care unit in critically ill patients

Abstract Background The need for cardiac intensive care unit (ICU) beds remains high in order to treat patients with severe cardiovascular diseases. Therefore, safe and timely discharge policies from the cardiac ICU to normal wards are crucial to meet the continuously increasing demand for cardiac ICU beds. ICU readmission after ICU discharge has been shown to increase mortality, hospital length of stay and costs. Artificial intelligence may provide a timely and accurate discharge decision support system for intensivists based on comprehensive, multi-dimensional ICU data. Purpose This is the first study to develop and validate a neuronal network, called Feedforward Neural Network (FNN), to safely discharge patients from the cardiac ICU and predict ICU readmission within 72 hours. Methods Adult patients who were admitted to the cardiac ICU due to a primary cardio-pulmonary admission diagnosis (such as acute myocardial infarction, cardiogenic shock or cardiac arrest) at a German tertiary care center between 2003 and 2021 were included. The dataset was split into a training and test dataset. The FNN was trained with 127 variables, including patient demographics, co-morbidities, medical diagnoses, disease acuity levels, laboratory values, vital parameters, ICU procedures and administered ICU medications. FNN was compared to the predictability of a classic logistic regression model and the Stability and Workload Index for Transfer (SWIFT) score, which is a clinical score to predict ICU readmission. Results 2,498 adult patients in the cardiac ICU met the inclusion criteria, out of which the FNN was trained in 1,998 (80.0%) patients and tested in 500 (20.0%) patients. The FNN had a 97.9% sensitivity, 86.9% specificity, 99.4% precision and 97.4% accuracy. FNN showed a better predictability of early ICU readmission than the logistic regression model and the SWIFT score: areas under the receiver operating characteristic (AUC ROC) curves were 90.78% vs. 71.34% vs. 71.13% (P &amp;lt;0.001) (Figure), respectively. Conclusions ICU transfer to the normal ward is considered to be a high-risk event and the vast amount of daily clinical, physiologic, laboratory and monitoring data may overwhelm critical care providers in making well informed decisions on patient discharge readiness. Artificial intelligence might be used as a sensitive, specific and accurate decision support system to help with patient discharge management and reduce ICU readmission rates.

Association between hospital onset of infection and outcomes in sepsis patients – A propensity score matched cohort study based on health claims data in Germany

BackgroundHospital-acquired infections are a common source of sepsis. Hospital onset of sepsis was found to be associated with higher acute mortality and hospital costs, yet its impact on long-term patient-relevant outcomes and costs is unknown. ObjectiveWe aimed to assess the association between sepsis origin and acute and long-term outcomes based on a nationwide population-based cohort of sepsis patients in Germany. MethodsThis retrospective cohort study used nationwide health claims data from 23 million health insurance beneficiaries. Sepsis patients with hospital-acquired infections (HAI) were identified by ICD-10-codes in a cohort of adult patients with hospital-treated sepsis between 2013 and 2014. Cases without these ICD-10-codes were considered as sepsis cases with community-acquired infection (CAI) and were matched with HAI sepsis patients by propensity score matching. Outcomes included in-hospital/12-month mortality and costs, as well as readmissions and nursing care dependency until 12 months postsepsis. ResultsWe matched 33,110 HAI sepsis patients with 28,614 CAI sepsis patients and 22,234 HAI sepsis hospital survivors with 19,364 CAI sepsis hospital survivors. HAI sepsis patients had a higher hospital mortality than CAI sepsis patients (32.8% vs. 25.4%, RR 1.3, p < .001). Similarly, 12-months postacute mortality was higher (37.2% vs. 30.1%, RR=1.2, p < .001). Hospital and 12-month health care costs were 178% and 22% higher in HAI patients than in CAI patients, respectively. Twelve months postsepsis, HAI sepsis survivors were more often newly dependent on nursing care (33.4% vs. 24.0%, RR=1.4, p < .001) and experienced 5% more hospital readmissions (mean number of readmissions: 2.1 vs. 2.0, p < .001). ConclusionsHAI sepsis patients face an increased risk of adverse outcomes both during the acute sepsis episode and in the long-term. Measures to prevent HAI and its progression into sepsis may be an opportunity to mitigate the burden of long-term impairments and costs of sepsis, e.g., by early detection of HAI progressing into sepsis, particularly in normal wards; adequate sepsis management and adherence to sepsis bundles in hospital-acquired sepsis; and an improved infection prevention and control.

Vascular Endothelial Growth Factor as Potential Biomarker for COVID-19 Severity.

COVID-19 is characterized by immunological responses to viral replication and coherent with endothelitis, microvascular disturbance of lung vasculature and coagulopathy. Vascular Endothelial Growth Factor (VEGF) is a proangiogenic mediator regulating endothelial changes. It is induced by proinflammatory signaling and hypoxia. We sought to determine whether VEGF levels differ between SARS-CoV-2-positive patients of different disease severity and whether VEGF might be useful in risk stratification. After retrospective screening of all SARS-CoV-2-positive patients treated in Unfallkrankenhaus Berlin in 2020, we included those with documented VEGF measurement. We extracted laboratory values and clinical parameters. An exploratory data analysis was performed to detect possible relations between VEGF level and clinical disease features. We included 167 SARS-CoV-2-positive patients of which 139 suffered from COVID-19. Seventy-one of the COVID-19 patients had to be treated in the intensive care unit (ICU), those patients exhibited higher VEGF levels than those being admitted to normal wards (535 vs 279 pg/L, P < .001). APACHE-2 (Acute Physiology And Chronic Health Evaluation Score) correlated with mortality and patients with high values showed higher VEGF concentrations on admission (456 vs 875 pg/L, p = 0.006). Receiver operating characteristic analytic revealed that the occurrence of organ dysfunctions like acute respiratory distress syndrome (ARDS), shock, or acute kidney injury could be predicted by VEGF. It was significantly higher in patients who later died compared to survivors (637 vs 389 pg/mL, P = 0.041) and predicted mortality with same accuracy as established markers. In our cohort, association of VEGF above 277 pg/L on admission with risk of ARDS could be confirmed in logistic regression adjusting for possible confounding factors (odds ratio 3.1, 95% confidence interval: 1.34-7.7). Even though there are several limitations to this retrospective study it revealed that in COVID-19 patients VEGF can contribute to the prediction of necessity of ICU, mortality and the prediction of ARDS, kidney injury or shock. Its use in risk stratification and potential pathogenetic involvement should be further investigated.

EPH203 Patients Characteristics, Vaccine Uptake, Healthcare Resource Utilization and Costs Associated with Acute COVID-19 during the Omicron Predominant Period in Brazil: A Nationwide Database Study

The coronavirus disease 2019 (COVID-19) pandemic has imposed significant burden on Brazil’s health system. The present study aims to describe patients’ demographic and clinical characteristics, vaccine uptake and assess healthcare resource utilization (HCRU) and costs associated with acute COVID-19 in Brazil during the Omicron predominant period. A population-based retrospective study was conducted using the National Health Data Network (RNDS), National Vaccination Campaign against COVID-19 data and surveillance data in public setting. Individuals with positive COVID-19 test results between January-April 2022 were identified. Patients’ demographics, comorbidities, vaccination status, HCRU for those who were admitted to hospitals and their associated costs were described by age groups. A total of 8,160,715 COVID-19 cases were identified and 2.7% were aged <5 years, 11.6% were 5-19 years, 76.9% were 20-64 years and 8.7% were ≥ 65 years. The presence of comorbidity was 23.1% with a higher prevalence of comorbidities in the elderly (61.8% for 65-74 years and 71.2% for ≥75 years). Regarding COVID -19 vaccination uptake, among those aged ≤19 years, 20-64 years and ≥65 years, 40.6%, 86.5% and 92.2% had primary series, respectively. Among adults, the booster uptake was 47.3% and 75.8% for those aged 20-64 years and ≥ 65 years, respectively. Among those with confirmed COVID-19, regardless of vaccination status, 87% were being symptomatic and 1.7% were hospitalized (3.8% in aged <5 years, 4.2% in 5-19 years, 34.3% in 20-64 years and 57.6% in ≥ 65 years). Among hospitalized patients, 32,6% were admitted to ICU and 80% required mechanical ventilation support. The average cost per day in normal wards and ICU without ventilation was R$291,89 and R$923,90, respectively. Our results quantify the public health and economic burden of COVID-19 in Brazil, suggesting substantial healthcare resources required to manage the COVID-19 pandemic.

Rising Incidence of Post Covid Rhinocerebral Mucormycosis: An Otolaryngologists Prospective.

Mucormycosis or grimmer popular name, "black fungus" has evolved public concern in context of covid-19 pandemic, Covid Associated Mucormycosis (CAM) seen in Covid-19 pandemic and as a post covid sequelae. The present study was conducted to find out the incidence of the Mucormycosis, and to study its association with post-covid status and co-morbidities. A retrospective study conducted at tertiary care centre over a period of four months, involving all patients with mucormycosis of the paranasal sinuses suffering from or having a history of coronavirus disease. 59 patients had CAM, 47 patients had rhino-orbital Mucormycosis, followed by nasal and paranasal Mucormycosis in 8 patients, 3 patients with rhino-orbital-cerebral Mucormycosis, and one patient with pulmonary Mucormycosis. Diabetes mellitus was present in all 59 patients, 60.41% who had HbA1c > 10 (range 7-15), and 39.58% had HbA1c < 10 with range 6-13. Only 8.33% had controlled diabetes status, uncontroled hypertension and diabetes was seen in 34.02%. All patients were started with IV amphotericin B anti-fungal drug, and followed by oral posaconazole. Depending upon the extent of the disease surgical debridement was done in 52 patients. All patients had history of steroid intake. 7 mortality was there. Uncontrolled diabetes, over-zealous use of steroids, uncontrolled underlying primary disease or co-morbidities, prolonged hospitalization in intensive care unit or normal wards, and hyperventilation all these factors together aggravated the CAM. So it's proper management based on, prompt diagnosis, reversal of predisposing condition with proper medical and aggressive surgical debridement remain the corner stone for this deadly CAM.

Management of the COVID-19 pandemic in Rhineland-Palatinate hospitals of all levels of care : Results of the COVID-19 Registry RLP.

The COVID-19 pandemic placed asignificant burden on the German healthcare system. Based on the experience of severe disease progression of the SARS-CoV‑2 infection from neighboring European countries in the early 2020s, with ICU overload and high mortality rates, efforts were made in Germany to increase the capacity of available ICU beds. Subsequently, all documentation and reporting focused on the ICU capacities for COVID-19patients. It was hypothesized that mainly afew large hospitals provided care for the majority of COVID-19patients. The COVID-19 Registry RLP of Rhineland-Palatinate documented SARS-CoV‑2 inpatients from daily mandatory queries of all hospitals throughout the pandemic from April 2020 to March 2023, distinguishing between patients in ICUs and normal wards. In its 18thCorona Ordinance, the state government required all hospitals to participate in the care of SARS-CoV‑2 inpatients. We investigated the participation of hospitals at different levels of care in Rhineland-Palatinate in the management of the COVID-19 pandemic. Nine pandemic waves were documented during the pandemic and exemplary data on the respective pandemic peaks were evaluated. Adistinction was made between the burden on hospitals at different levels of care: primary care hospitals, standard care hospitals, specialty hospitals, and maximal care hospitals. Analysis of the data showed that all hospital types participated equally in the care of SARS-CoV-2patients. The requirement of the Ministry of Health of Rhineland-Palatinate to provide at least 20% of the available capacity was met by all levels of care and there were no disparities between hospitals of different levels of care in the management of the pandemic.Hospitals at all levels of care participated equally in the care of SARS-CoV‑2 inpatients and thus contributed significantly to the management of the pandemic in Rhineland-Palatinate.

Health-economic modelling of cost savings due to the use of rezafungin based on a German cost-of-illness study of candidiasis.

Candida species are responsible for fungal diseases and the development of nosocomial bloodstream infections. Treatment is resource-intensive and economically challenging for healthcare systems. Cost analyses of drugs against candidiasis, such as rezafungin, are thus of great interest to healthcare payers. We conducted a cost-of-illness study of patients with Candida infections based on real-word data of the Department I of Internal Medicine, University Hospital Cologne (Germany) between 2016 and 2021. Health-economic parameters were analysed to describe the economic impact of Candida infections. Potential cost savings due to the administration of rezafungin were modelled for patients with invasive candidiasis or candidaemia based on a 5 day reduction of ICU length of stay (LOS) shown by the STRIVE study. We found 724 cases (652 patients) with Candida infections, of which 61% received ICU treatment (n = 442) and 29% were mechanically ventilated (n = 207). Twenty-six percent died during hospitalization (n = 185). Median LOS was 25 and 15 days, on normal wards and ICU, respectively. Median total treatment costs per case accounted for €22 820. Based on the ICU LOS reduction, the retrospective model showed a median cost-saving potential of €7175 per hospital case with invasive candidiasis or candidaemia. Accumulated cost savings for 37 patients of €283 335 were found. Treatment of candidiasis is cost intensive due to increased hospital LOS. The ICU LOS reduction rezafungin showed in STRIVE would lead to sustainable cost savings.

Systematic risk management for aplanned gas shutdown in the high-care facility of auniversity hospital

In the course of building extension works at Dresden University Hospital, it was necessary to shut down the central medical gas supply in abuilding with 3 intensive care wards with 22beds, an operating theater tract with 5 operating rooms and 6 normal wards each with 28beds during ongoing services. Thus, for the construction phase there was aneed to establish an interim decentralized gas supply with zero failure tolerance for the affected functional units . Following established procedures for possible risk and failure analysis, aproject group was set up by the hospital's emergency and disaster management officer to develop aproject plan, aneeds assessment and acommunication plan. Avariety of risk factors were systematically identified for which appropriate countermeasures needed to be designed. The needs assessment over 4 h based on physiological parameters for the maximum available 22ventilator beds resulted in 26,000 l of oxygen and 26,000 l of compressed air. A total of 7 supply points were each equipped with two 50l cylinders for both oxygen and compressed air, with atotal availability of 175,000 l of each of the 2 gases. Another eight cylinders each were held in reserve. The project was carried out on aSaturday without an elective surgery program, so that the operating rooms concerned could be closed. The timing was chosen so that double staffing of intensive care personnel was available during the afternoon shift change. In advance, as many of the patients on mechanical ventilation as possible were transferred within the hospital; however, nine of the mechanically ventilated patients had to remain. The technical intervention in the gas supply lasted only 2 h without affecting the patient's condition. During the 2‑h interim supply, 16,500 l of compressed air and 8000 l of oxygen were consumed on the high-care wards. The calculated hourly consumption per ventilated patient was 917 l of air (15 l/min) and 444 l of oxygen (7 l/min). The quantity framework based on empirical values from intensive care medicine was significantly lower. This was more than compensated for by the 10-fold stocking of gas and the predictably lower number of ventilated patients than the maximum occupancy used as abasis. For technical interventions in high-risk areas, careful planning and execution in an effective team is required. Established procedures of project management and risk assessment help to avoid errors.

Compliance assessment regarding the PVC management on normal wards of a university hospital.

The risk of peripheral venous catheter (PVC) infections in inpatients is often underestimated, even if it is lower than that for central venous catheters. Guidelines for the prevention of PVC-associated infections describe the evidence-based management of PVCs. The aims of this study were the development of standardized methods for compliance assessment regarding PVC management and the evaluation of self-reported knowledge and implementations among healthcare providers regarding PVC care. We developed a checklist based on the recommendation of the Commission of Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO) Berlin for the standardized evaluation of PVC management. The following parameters were collected and evaluated: condition of the puncture site, condition of the bandage, presence of an extension set, presence of a plug, and documentation. The checklist was applied in 14 normal wards in 2019. After feedback of the ward staff on the results, it was applied again in 2020 in the same wards. For retrospective data analysis, we used a newly developed PVC-quality index. After the second evaluation in 2020, we carried out an anonymous survey among the healthcare providers. The evaluation of 627 indwelling PVCs showed a significant increase in compliance related to the presence of an extension set (p=0.049) and documentation (p<0.001) in the 2nd year. The quality index increased in 12 out of 14 wards. The participants of the survey were aware of the in-house standard "Prevention of vascular catheter-associated infections", with a mean score of 4.98 on a Likert scale (1=not aware, 7=completely aware). The main barrier to implementation of the preventive measures was the time factor. Survey participants were more aware of PVC placement than PVC care. The PVC quality index is a valuable tool for the assessment of compliance regarding PVC management in daily practice. Feedback from the ward staff on the results of compliance assessment improves PVC management, but the outcome is very heterogeneous.

Elektrolytstörungen in der Intensivmedizin

Electrolyte disorders frequently occur in intensive care medicine and can influence mortality and morbidity. A rapid diagnostic evaluation is required for adequate treatment but in individual cases, this should not delay the necessary correction of the electrolyte disorder. Hyponatremia with severe symptoms, such as seizures or coma usually requires the administration of 3% NaCl, while less clinically severe forms should initially be diagnostically assessed and then be specifically treated. Hypernatremia occurs particularly frequently in intensive care medicine and should be treated based on the genesis as hypernatremia is associated with increased mortality. Hyperkalemia and hypokalemia should be rapidly diagnosed and treated given the increased risk of cardiac arrhythmia. While hypophosphatemia plays a subordinate role on normal wards, on the intensive care unit it must be diagnosed and subsequently substituted as this can reduce mortality.

Abstract 225: Late Awakening In Comatose Survivors Of Out-of-hospital Cardiac Arrest

Background: Despite advanced neuroprognostication using neuron-specific enolase, electroencephalogram and brain imaging, prediction of neurological outcome in comatose survivors of out-of-hospital cardiac arrest (OHCA) remain challenging and early discontinuation of postresuscitation treatment may be harmful for patients with delayed awakening. Hypothesis: Significant proportion of comatose survivors of OHCA may regain consciousness only after discharge from intensive care unit (ICU). Methods: Consecutive comatose survivors of OHCA admitted to our ICU between January 1, 2003 and December 31, 2021 were investigated. Cerebral performance category (CPC) was used for evaluation of neurological recovery. CPC 1 indicated complete recovery, CPC 2 mild neurological impairment, CPC 3 severe neurological impairment and CPC 4 vegetative state. Results: A total of 1098 patients (63 + 14 years, 79% (864 of 1098) men) were enrolled. OHCA was witnessed in 88% (966 of 1098), basic life support was performed in 57% 630 of 1098), delay to emergency team arrival was 7.5 + 5.3 minutes and initial shockable rhythm was present in 77%. (851 of 1098). Reestablishment of spontaneous circulation (ROSC) was obtained after 12.9 + 11.8 minutes of advanced life support. Coronary angiography was performed in 74% (822 of 1098) and percutaneous coronary intervention in 52% (567 of 1098). Mechanical circulatory support was used in 16% (175 of 1098) and hypothermia (32-34 C) in 85% (940 of 1098). Among 740 patients who survived to ICU discharge on day 7 (median), 272 patients (36.8%) of patients remained in CPC 3-4 ( Figure). Among these 272 patients, CPC 1-2 at hospital discharge was documented in 19.9%. (54 patients). Conclusion: Almost 20% of comatose survivors of OHCA without neurological recovery at ICU discharge may ultimately regain consciousness. This argues against premature withdrawal of care in step down units and normal wards.

Resuming Swallowing and Oral Feeding in Tracheostomized COVID-19 Patients: Experience of a Swiss COVID-Center and Narrative Literature Review.

During the COVID-19 pandemic, percutaneous tracheostomy proved to be an effective option in the management of patients with prolonged periods of intubation. In fact, among other things, it allowed early discharge from ICUs and contributed to reducing overcrowding in intensive care settings, a central and critical point in the COVID pandemic. As a direct consequence, the management and the weaning of frail, tracheostomized and ventilated patients was diverted to sub-intensive or normal hospitalization wards. One central challenge in this setting is the resumption of swallowing and oral feeding, which require interdisciplinary management involving a phoniatrician, ENT, pneumologist, and speech therapist. With this article, we aim to share the experience of a Swiss COVID-19 Center and to draw up a narrative review on the issues concerning the management of the tracheostomy cannula during swallowing resumption, integrating the most recent evidence from the literature with the clinical experiences of the professionals directly involved in the management of tracheostomized COVID-19 patients. In view of the heterogeneity of COVID-19 patients, we believe that the procedures described in the article are applicable to a larger population of patients undergoing tracheostomy weaning.

Carbon footprinting for hospital care pathways based on routine diagnosis‐related group (DRG) accounting data in Germany: An application to acute decompensated heart failure

AbstractA general framework is developed using routine German diagnosis‐related group (G‐DRG) accounting data to estimate carbon footprints of hospital care pathways in the context of patients with acute decompensated heart failure (ADHF) admitted to the Red Cross Hospital Bremen in 2018. Financial activity data encompass G‐DRG material costs from hospital accounting data submitted to the Institute for the Hospital Remuneration System. A set of seven greenhouse gases (GHGs) is included. Environmentally extended input–output emission factors (EFs) compiled by Eurostat are employed. EFs of cost modules are calculated separately considering respective emissions' intensities. Total emissions reach 72,652 kg carbon dioxide equivalent (CO2e) (nonbiogenic: 85.5%; biogenic: 14.5%) for general inpatient care throughout ADHF patient care pathways in 2018. Emissions from normal wards account for the largest proportion (74.8%) of total emissions for ADHF patients. Compared to other matched industry categories, cost‐types covered by the industry category D “electricity, steam and air conditioning supply” cause the vast majority (approximately 87%) of total emissions. GHG emissions per unit of analysis, per bed day, and per euro are estimated at 263, 32, and 0.31 kg CO2e, respectively. Although this framework is currently limited to hospitals that participate in the G‐DRG calculation scheme or apply these accounting standards on a voluntary basis, it has particular advantages that render it amenable to other contexts. It enables the calculation of emissions separately for each cost module considering its specific emission intensity, which can improve the accuracy of estimates.

Admission and Mortality Patterns in Intensive Care Delivery at Enugu State University of Science and Technology Teaching Hospital: A Three-Year Retrospective Study.

BackgroundThe intensive care unit (ICU) provides critical care to high-risk patients to prevent morbidity and mortality. This requires closer monitoring and better management than the care provided to patients in normal admission wards and non-critical care units. Mortality rates in ICUs in developing countries are remarkably high compared to rates in more developed countries. Evaluating outcomes of treatment is a way to improve the quality of care. Therefore, this study was conducted to review the pattern of admission and outcome in the ICU of Enugu State University of Science and Technology Teaching Hospital (ESUT-TH).MethodologyThis study was a three-year retrospective, descriptive review of all patients admitted to the ICU of ESUT-TH between January 1, 2019, and December 21, 2021. Data were collected from admissions and discharge registers of the ICU ward. Data were analyzed and expressed as frequencies and percentages. Categorical parameters were compared using the chi-squared test, and the significance level was set at p < 0.05.ResultsA total of 179 patients were admitted in the three-year period. Of them, 49.2% were postoperative patients while 21.2% were admitted from the accident and emergency unit. There were a total of 74 (41.3%) medical cases and 81 (45.3%) surgical cases, and the rest were unspecified. Among surgical cases, 19% were from the general surgery department followed by obstetrics and gynecology (18.4%) and neurosurgery (16.8%). Cerebrovascular accidents and traumatic brain injury were the most common specific diagnoses recorded among ICU admitted patients. The most common reason for admission was close monitoring of high-risk patients. The mortality rate during the studied period was 34.1%, and this was significantly associated with patient age and type of illness at presentation (p < 0.05). Stratified by year of admission, the highest rate of mortality was noted in the year 2020 (46.7%).ConclusionThere is a high level of mortality among ICU admissions in our center. This calls for the improvement of intensive care delivery in the healthcare facility, including training and retraining of manpower and provision of essential facilities for high-quality healthcare delivery.

Possible Alterations of Imaging Patterns in Computed Tomography for Delta-VOC of SARS-CoV-2.

So far, typical findings for COVID-19 in computed tomography (CT) have been described as bilateral, multifocal ground glass opacities (GGOs) and consolidations, as well as intralobular and interlobular septal thickening. On the contrary, round consolidations with the halo sign are considered uncommon and are typically found in fungal infections, such as invasive pulmonary aspergillosis. The authors recently observed several patients with COVID-19 pneumonia presenting with round, multifocal consolidations accompanied by a halo sign. As this may indicate alterations of CT morphology based on the virus variant, the aim of this study was to investigate this matter in more detail. 161 CT scans of patients with confirmed SARS-CoV-2 infection (RT-PCR within 2 days of CT) examined between January 2021 and September 15, 2021 were included. Follow-up examinations, patients with invasive ventilation at the time of CT, and patients with insufficient virus typing for variants of concern (VOC) were excluded. CT scans were assessed for vertical and axial distribution of pulmonary patterns, degree of involvement, uni- vs. bilaterality, reticulations, and other common findings. The mean density of representative lesions was assessed in Hounsfield units. Results were compared using Mann-Whitney U-tests, Student's t-rests, descriptive statistics, and Fisher's exact tests. 75 patients did not meet the inclusion criteria. Therefore, 86/161 CT scans of unique patients were analyzed. PCR VOC testing confirmed manifestation of the Delta-VOC SARS-CoV-2 in 22 patients, 39 patients with Alpha-VOC and the remaining 25 patients with Non-VOC SARS-CoV-2 infections. Three patients with the Delta-VOC demonstrated multiple pulmonary masses or nodules with surrounding halo sign, whereas no patients with either Alpha-VOC (p = 0.043) or non-VOC (p = 0.095) demonstrated these findings. All three patients were admitted to normal wards and had no suspicion of a pulmonary co-infection. Patients with Delta-VOC were less likely to have ground glass opacities compared to Alpha-VOC (7/22 or 31.8 % vs. 4/39 or 10.3 %; p < 0.001), whereas a significant difference has not been observed between Delta-VOC and non-VOC (5/25 or 20 %; p = 0.348). The mean representative density of lesions did not show significant differences between the studied cohorts. In this study 3 out of 22 patients (13.6 %) with Delta-VOC presented with bilateral round pulmonary masses or nodules with surrounding halo signs, which has not been established as a notable imaging pattern in COVID-19 pneumonia yet. Compared to the other cohorts, a lesser percentage of patients with Delta-VOC presented with ground glass opacities. Based on these results Delta-VOC might cause a divergence in CT-morphologic phenotype. · Until recently, CT-morphologic signs of COVID-19 pneumonia have been presumed to be uncontroversially understood. Yet, recently the authors observed diverging pulmonary alterations in patients infected with Delta-VOC.. · These imaging alterations included round pulmonary masses or nodules with surrounding halo sign.. · These imaging alterations have not yet been established as typical for COVID-19 pneumonia, yet.. · Based on these results, Delta-VOC could impose a divergence of CT-morphologic phenotype.. · Yüksel C, Sähn M, Kleines M et al. Possible Alterations of Imaging Patterns in Computed Tomography for Delta-VOC of SARS-CoV-2 . Fortschr Röntgenstr 2022; 194: 1229 - 1241.

Comparison of the Relationship Between SI and RASI Scores With the Outcome of Sepsis Patients.

The aim of this study was to compare the relationship between shock index (SI) and respiratory adjusted shock index (RASI) scores with the final outcome of sepsis patients referred to the emergency department. This was prospective research that examined individuals who had been diagnosed with sepsis, determined by the presence of at least two of the three quick sepsis-related organ failure assessment (qSOFA) criteria and the presence of an infectious disease based on a diagnosis made by a hospital physician of Imam Reza and Ghaemshahr of Mashhad in 2019. Demographic information of patients, SI score, RASI score, and information related to the patient's clinical symptoms were recorded in the checklist. The final outcome of this study was considered mortality. Data analysis was performed using descriptive and inferential tests. In the present study, a total of 178 patients, 46 patients (25.8%) were transferred to the intensive care unit, and 98 patients (55.1%) were admitted to the normal wards. Eighty-five patients (47.75%) died and the mean length of hospital stay of all patients was 11.07 ± 9.23 days. Forty-four patients (24.7%) had referred with a decreased level of consciousness and 44 patients (24.7%) presented with confusion. The rest of the patients reported normal levels of consciousness. Kaplan Mir analysis with log-rank was performed to determine the difference in survival distribution in different SI groups: Survival distribution was not statistically different for the four defined groups (based on statistical quartiles (P = 0.320). Receiver operator curves were considered as the date of death in the case of the deceased and the date of discharge from the hospital in the case of the living as censored. The AUC of the RASI scoring system for predicting mortality was 0.614 (P = 0.009) while this value was not significant for SI (P = 0.152). In logistic regression analysis, it was found that by adjusting for the variables of age, sex, sepsis etiology, blood pressure and heart rate, level of consciousness, and gender, patients with the lower respiratory rate (OR 1.6, z = −0.159 p = 0.007), younger age (OR 1.6, z = −0.029 p = 0.006) and higher RASI score are more in risk of mortality (OR 1.29, z = 1.209, p = 0.031). The results of our study showed that RASI scoring can be a good criterion for predicting the chance of mortality in patients with sepsis and could be used complementary to previous criteria such as SI. Patients with high RASI scores should be given more attention to reducing the chance of death.

P wave peak time and P wave dispersion in severe COVID-19 infection.

With this study, we aimed at evaluating the association between electrocardiographic P wave indices and the severity of COVID-19 infection indicated as intensive care unit (ICU) admission. We included 247 patients who were hospitalized with a diagnosis of COVID-19 infection and underwent 12 lead standard Electrocardiography (ECG). P wave indices, P wave dispersion (Pdis), P wave peak time in V1 lead (PWPTV1), and D2 lead (PWPTD2) were measured using admission ECG. Comparisons were performed between ICU admitting and non-ICU admitting patients. 160 patients were hospitalized in normal wards, and 87 patients were admitted to ICU. Pdis, PWPTV1, and PWPTD2 were prolonged in ICU admitted patients compared with the normal ward admitted patients [40 (30-50) ms vs. 50 (40-55) ms; p<0.001, 61±9 ms vs. 68±9 ms; p<0.001, and 55±7 ms vs. 64±7 ms; p<0.001, respectively]. In multiple logistic regression analysis, PWPTV1 and PWPTD2 were independent predictors of ICU admission. A cut-off point of 67.5 ms PWPTv1 has a sensitivity of 62.1% and a specificity of 69.4% (AUC=0.710, 95% CI: 0.642-0.777, p<0.001) and a cut-off point of 62.5 ms PWPTD2 has a sensitivity of 60.9% and a specificity of 83.6% (AUC=0.819, 95% CI: 0.777-0.871, p<0.001). Admission ECG atrial indices Pdis and PWPT were associated with intensive care unit admission in newly diagnosed COVID-19 patients.