Outcome In ICU Patients Research Articles

New ICU Design and Patient Outcome

Hospital length of stay (LOS) is a quality metric health systems use as a proxy of efficient hospital management (1). Many strategies to reduce ICU length of stay (LOS) have been implemented, but few studies have evaluated the role of ICU design in reduction of LOS and outcome. This study was informed by the need to compare ICU performance in terms of length of stay and outcome before the upgrade of the ICU facilities and organizational structure (January 2018 – December 2019) and after upgrade of the ICU facilities (January 2020 – December 2021). Finally we demonstrate the impact of ICU design in reducing costs of ICU patients.

New ICU Design and Patient Outcome

New ICU Design and Patient Outcome

Demographic features, laboratory findings and outcomes of ICU patients with COVID-19 in Ahvaz, Iran: A single-centered prospective study.

COVID-19 can lead to severe acute respiratory syndrome so that some patients need to be admitted to the Intensive Care Unit (ICU). The aim of the current study is to investigate the frequency of demographic, laboratory and imaging findings and type of treatment and their relationship with disease outcomes in patients with COVID-19. This prospective cross-sectional study was conducted on all patients with COVID-19 who were admitted in the ICU of Razi Hospital in Ahvaz, Iran from January 20 to February 20, 2021. Patient information including demographic features, laboratory and imaging findings and clinical outcomes was recorded. One hundred and thirty-three patients were recruited in the present study, out of which 74 patients (55.6%) were males and 59 patients (44.4%) were females. The overall mortality rate of patients was 35.3% (47 patients) and was higher in patients over 65 years of age. There was a significant difference in terms of thrombocytopenia (P value: 0.001), lymphopenia (P value: 0.004), progression of lung involvement in imaging, shock, disseminated intravascular coagulation (DIC), sepsis and receiving invasive respiratory support in living and deceased patients (P value < 0.001). Furthermore, the difference in life status and the length of in-ICU stay in patients with hyperkalemia and renal failure was statistically significant (P value = 0.033, P value < 0.001 respectively). Mortality rate of patients with COVID- 19 admitted to ICU is generally high. According to the findings of this study, thrombocytopenia, lymphopenia, hyperkalemia and AKI are laboratory disorders associated with increased mortality. Moreover, the progression of pulmonary involvement in imaging, shock, DIC, sepsis, and need to invasive respiratory support is associated with low survival of patients.

Sequential APACHE II Scores for Prediction of Mortality in Patients with Severe Malaria and Admitted to Critical Care Facilities

Background/Aims: Both generic and disease specific prognostic scoring systems have been employed in areas of critical care. The score of Acute Physiology and Chronic Health Evaluation (APACHE) II is a generic point score which provides general assessment of illness and severity. In order to determine the mortality of critically ill malaria patients, this study aims to find the ideal time point for the APACHE II score.&#x0D; Materials and Methods: This longitudinal study was carried out after getting necessary ethics committee approval. Score of APACHE II on days 0, 2nd and 7th were evaluated and appropriate statistical tests were applied.&#x0D; Results: Out of 120 patients, 54 patients were of P. vivax, P. falciparum - 60 and six mixed infection patients. Mean APACHE II score was maximum on day 0 followed by day 2 and 7 in decreasing order. The APACHE II score was statistically greater on all days in patients who didn’t survive. The Receiver Operating Characteristic (ROC) curve when plotted showed score of APACHE II on day 2 - cut-off ≥14 to be the most valid in mortality prediction with a sensitivity of 64.28% and specificity of 87.80% as most of the results were on the left from the diagonal line and had greatest area under the curve.&#x0D; Conclusion: The prognostic score APACHE II was discovered to be helpful in patients with severe falciparum/vivax malaria who required intensive care treatment since the second day's sequential score significantly differentiates between survivors and non-survivors. The optimum cut-off for identifying individuals at high risk of mortality is 14, and the Day-2 APACHE II score is an ideal biomarker for predicting the outcomes of ICU patients.&#x0D; Recommendation: Malaria is a major cause of tropical sepsis in India leading to significant amount of mortality. Sequential APACHE II scoring instead of single time APACHE II score calculated on admission could have a role in evaluation of effectiveness of treatment, trend in recovery or dysfunction and prediction of mortality.

Characteristics and Outcomes of ICU Patients Without COVID-19 Infection-Pandemic Versus Nonpandemic Times: A Population-Based Cohort Study.

To demonstrate the characteristics and outcomes of non-COVID patients admitted to an ICU during the pandemic, compared with the previous year. A population-based study conducted using linked health administrative data comparing a cohort from March 1, 2020, to June 30, 2020 (pandemic) to a cohort from March 1, 2019, to June 30, 2019 (nonpandemic). Adult patients (18 yr old) admitted to an ICU in Ontario, Canada, without a diagnosis of COVID-19 during the pandemic and nonpandemic periods. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included hospital and ICU length of stay, discharge disposition, and receipt of resource intensive procedures (e.g., extracorporeal membrane oxygenation, mechanical ventilation, renal replacement therapy, bronchoscopy, feeding tube insertion, and cardiac device insertion). We identified 32,486 patients in the pandemic cohort and 41,128 in the nonpandemic cohort. Age, sex, and markers of disease severity were similar. Fewer patients in the pandemic cohort were from long-term care facilities and had fewer cardiovascular comorbidities. There was an increase in all-cause in-hospital mortality among the pandemic cohort (13.5% vs 12.5%; p < 0.001) representing a relative increase of 7.9% (adjusted odds ratio, 1.10; 95% CI, 1.05-1.56). Patients in the pandemic cohort admitted with chronic obstructive pulmonary disease exacerbation had an increase in all-cause mortality (17.0% vs 13.2%; p = 0.013), a relative increase of 29%. Mortality among recent immigrants was higher in the pandemic cohort compared with the nonpandemic cohort (13.0% vs 11.4%; p = 0.038), a relative increase of 14%. Length of stay and receipt of intensive procedures were similar. We found a modest increase in mortality among non-COVID ICU patients during the pandemic compared with a nonpandemic cohort. Future pandemic responses should consider the impact of the pandemic on all patients to preserve quality of care.

Relationship Between Parenteral Energy/Amino Acids And Clinical Outcomes In Long-Term Fasting Icu Patients: A Retrospective Cohort Study Using Japanese Medical Claims Database

Relationship Between Parenteral Energy/Amino Acids And Clinical Outcomes In Long-Term Fasting Icu Patients: A Retrospective Cohort Study Using Japanese Medical Claims Database

Integrating Structured and Unstructured EHR Data for Predicting Mortality by Machine Learning and Latent Dirichlet Allocation Method.

An ICU is a critical care unit that provides advanced medical support and continuous monitoring for patients with severe illnesses or injuries. Predicting the mortality rate of ICU patients can not only improve patient outcomes, but also optimize resource allocation. Many studies have attempted to create scoring systems and models that predict the mortality of ICU patients using large amounts of structured clinical data. However, unstructured clinical data recorded during patient admission, such as notes made by physicians, is often overlooked. This study used the MIMIC-III database to predict mortality in ICU patients. In the first part of the study, only eight structured variables were used, including the six basic vital signs, the GCS, and the patient's age at admission. In the second part, unstructured predictor variables were extracted from the initial diagnosis made by physicians when the patients were admitted to the hospital and analyzed using Latent Dirichlet Allocation techniques. The structured and unstructured data were combined using machine learning methods to create a mortality risk prediction model for ICU patients. The results showed that combining structured and unstructured data improved the accuracy of the prediction of clinical outcomes in ICU patients over time. The model achieved an AUROC of 0.88, indicating accurate prediction of patient vital status. Additionally, the model was able to predict patient clinical outcomes over time, successfully identifying important variables. This study demonstrated that a small number of easily collectible structured variables, combined with unstructured data and analyzed using LDA topic modeling, can significantly improve the predictive performance of a mortality risk prediction model for ICU patients. These results suggest that initial clinical observations and diagnoses of ICU patients contain valuable information that can aid ICU medical and nursing staff in making important clinical decisions.

Association between histamine 2 receptor antagonists and sepsis outcomes in ICU patients: a retrospective analysis using the MIMI-IV database

BackgroundSepsis is marked by elevated histamine, which is a vasodilator that increases vascular permeability. Although human studies are lacking, murine models of sepsis have indicated potential protective effects of histamine 2 receptor antagonist administration (H2RAs).ObjectiveTo assess any association between H2RA use in sepsis-3 patients admitted to the ICU and mortality, mechanical ventilation, length of stay, and markers of renal, liver, and lung dysfunction.DesignRetrospective cohort study.SettingIntensive care units of the Beth Israel Deaconess Medical Center (BIDMC) accessed via the MIMIC-IV database spanning an 11-year period from 2008 to 2019.Patients (or participants)A total of 30,591 patients met the inclusion criteria for sepsis-3 on admission (mean age 66.49, standard deviation 15.92).Main measuresWe collected patient age, gender, ethnicity, comorbidities (contained within the Charlson comorbidity index), SOFA score, OASIS score, APS III score, SAPS II score, H2RA use, creatinine, BUN, ALT, AST, and P/F ratios. Primary outcomes were mortality, mechanical ventilation, and ICU length of stay.Key resultsA total of 30,591 patients met inclusion criteria over the 11-year sample period. The 28-day in hospital mortality rate was significantly lower among patients who received an H2RA (12.6% vs 15.1%, p < 0.001) as compared to those who did not receive an H2RA. Patients receiving an H2RA had significantly lower adjusted odds of mortality (0.802, 95% CI 0.741–0.869, p < 0.001), but significantly higher adjusted odds of invasive mechanical ventilation (4.426, 95% CI 4.132–4.741, p < 0.001) and significantly higher ICU LOS (3.2 days vs. 2.4 days, p < 0.001) as compared to the non-H2RA group. H2RA use was also associated with decreased severity of acute respiratory distress syndrome (ARDS) and lower serum creatinine.ConclusionAmong patients hospitalized in the ICU for sepsis, the use of an H2RA was associated with significantly lower odds of mortality, decreased severity of ARDS, and a lower incidence of renal insufficiency.

Increased ICU mortality in septic shock patients with hypo- or hyper- serum osmolarity: A retrospective study.

While many factors that are associated with increased mortality in septic shock patients have been identified, the effects of serum osmolarity on the outcomes of ICU patients with septic shock have not yet been studied. The present study was designed to examine the association of serum osmolarity with ICU 28-day mortality in ICU patients with septic shock. Adult patients diagnosed with septic shock from the MIMIC-IV database were selected in this study. The serum osmolarity was calculated synchronously according to the serum concentrations of Na+, K+, glucose, and urea nitrogen. In the present study, a significant difference was observed between the 28-day mortality of septic shock patients with hypo-osmolarity, hyper-osmolarity, and normal osmolarity (30.8%, 34.9%, and 23.0%, respectively, p < 0.001), which were detected at ICU admission. After propensity score matching (PSM) for basic characteristics, the relatively higher mortality was still observed in the hypo-osmolarity and hyper-osmolarity groups, compared to normal osmolarity group (30.6%, 30.0% vs. 21.7%, p = 0.009). Furthermore, we found that transforming the hyper-osmolarity into normal osmolarity by fluid therapy on day 2 and 3 decreased this mortality. The serum osmolarity disorder is markedly associated with increased 28-day mortality in septic shock patients.

An importance of respiratory drive and effort during mechanical ventilation

During mechanical ventilation, minimizing respiratory drive and effort becomes routine to prevent patient-ventilator asynchrony (PVA). As we know, PAV associates with poor outcomes in ICU patients. As a result, prescribing sedative drugs in combination with neuro-muscular blocking agents commonly appears in many ICUs. However, many patients develop adverse events from unloading respiratory muscles, resulting in prolonged mechanical ventilator and bad clinical outcomes. This review describes both sides of the adverse effect of respiratory drive and effort and tries to suggest the optimum point, believing that it may be associated with better outcomes.

Enteral therapy in patients with blunt abdominal trauma

To improve the outcomes in ICU patients with blunt abdominal trauma via enteral therapy by saline enteral solution. A retrospective and prospective study included 24 patients (18 (75%) men and 6 (25%) women) with blunt abdominal trauma who underwent examination and treatment at the Sklifosovsky Research Institute for Emergency Care. Age of patients ranged from 38 to 81 years (mean 50.1±13.6). Enteral therapy was followed by normalization of serum lactate, alanine aminotransferase and aspartate aminotransferase after 3 days. There were significant differences in decrease of lactate dehydrogenase, alanine aminotransferase and C-reactive protein. In the control group, these parameters decreased only by the 10th day. Inclusion of saline enteral solution into the complex therapy contributes to earlier recovery of gastrointestinal function and prevents compartment syndrome. These aspects reduced the number of patients with multiple organ failure.

Clinical trial validation of the STAR-3D glycemic control framework

Glycemic control (GC) to regulate dysglycemia in critically ill patients is associated with improved outcomes. However, it has been hard to achieve safely due to metabolic variability. Protocol design is critical to provide safe, effective control to all patients. STAR is a unique model-based, patient-specific, and risk-based glycemic control framework accounting for inter- and intra- patient variability using a clinically validated digital twin model. This study presents the first clinical trial results of STAR with a new 3D stochastic model, which was shown to improve predictions of patient-specific insulin sensitivity variability and value in validated virtual trials, and can thus potentially improve glycemic control outcomes.In total, 616 patients are considered in this analysis, totaling 37489 hours of control. Overall, 77% of blood glucose (BG) measurements were in target, with a median BG of 6.7 mmol/L. There was no incidence of severe hypoglycemia (BG < 2.2 mmol/L) and only 0.3% of mild hypoglycemia (BG < 4.0 mmol/L). These results were achieved with a median [25th 75th percentiles] of 4.0 [2.0 6.0] U/h of insulin, and nutrition rates with median 100 [83 100] % of goal feed. These results were consistent when considering per-patient statistics.Using this new tri-variate stochastic model in the STAR glycemic control framework successfully provided extremely safe, effective GC for all patients, with high nutrition intake, despite targeting normoglycemic ranges. High safety from hypoglycemia, high %BG in normoglycemia, and high nutrition delivery are all associated with improved outcome in ICU patients.

Retracted: Influence of Dexmedetomidine on Diaphragm Function and Postoperative Outcomes in ICU Patients with Mechanical Ventilation.

[This retracts the article DOI: 10.1155/2021/1990838.].

996: MAXIMIZING THE GOLDEN HOUR IN CRITICALLY ILL PATIENTS: ASSESSMENT GAPS AT THE TIME OF ADMISSION

Introduction: The “golden hour” is the concept that timely assessment and resuscitation can improve outcomes in the critically ill. These principles are well-established in trauma patients, and rapid administration of evidence-based interventions has also been shown to improve outcomes in patients with sepsis. The best approach to perform this rapid evaluation and treatment, however, has not been previously evaluated in the ICU. Our aims are to observe common approaches to the assessment of critically ill patients upon ICU admission, to compare them to the established Checklist for Early Recognition and Treatment of Acute Illness and iNjury (CERTAIN) that has been associated with improved patient outcomes, and to examine the impact of observed variations in practice. Methods: We conducted a prospective observational study in Mayo Clinic ICUs. We recorded ICU team actions during patient admissions, including performance of primary assessment, vital signs, IV access confirmation, labs and ultrasound, differential diagnosis, and plan by systems, including code status. Data were analyzed to identify practice patterns, assessment gaps, and length of stay. Results: Data on 16 MICU patient observations has been analyzed to date. The patient median age was 65.5 years, 40% were female, and the mean ICU length of stay was 2.7 days. Recorded frequency of airway assessment was 73%, breathing 73%, circulation 93%, disability 33%, and exposure 80%. 73% of patients had their vital signs evaluated, and 60 % had IV/IO access obtained. 62% had cardiac POCUS, while only 31% had lung ultrasound and 25% had an abdominal ultrasound. The most frequently addressed systems during the discussion of plans were cardiovascular and pulmonary at 62% and 75%, with neurologic and hematologic discussed in 25%. The least commonly discussed system was endocrine (12.5%). Nurses completed 36% of admission tasks, while 50% of plan by system tasks were completed by residents. Conclusions: We describe variations in assessment during admission. Gaps in assessment are frequently observed during the golden hour compared to the CERTAIN checklist, arguing that a systematic approach is necessary to avoid errors of omission. Additional research is needed to determine the impact of these variations in practice on ICU patient outcomes.

Effects of sodium bicarbonate infusion on mortality in medical-surgical ICU patients with metabolic acidosis-A single-center propensity score matched analysis.

Metabolic acidosis is associated with high mortality. Despite theoretical benefits of sodium-bicarbonate (SB), current evidence remains controversial. We investigated SB-related effects on outcomes in ICU patients with metabolic acidosis. Retrospective analysis. Academic medical center. 971 ICU patients with metabolic acidosis defined as arterial pH<7.3 and CO2<45mmHg treated between 2012 and 2016. A propensity score (PS) was estimated using logistic regression. Patients were matched in pairs using the PS. 441 patients were treated with SB 8.4% (SB-group) and n=530 patients were not (control group). Primary outcome was all-cause mortality at ICU-discharge. Average Treatment Effect (ATE), Average Treatment effect in Treated (ATT), and estimated relative survival effects at 20 days were computed. In the full cohort, we observed considerable differences in pH, base excess, additional acidosis-related indices, and ICU mortality (controls 31% vs. SB-group 56%, p<.001) at baseline between the two groups. After PS-matching (n=174 in each group), no significant difference in ICU mortality was observed (controls 32% vs. SB-group 41%; p=.07). Odds ratios (OR) for ATE and ATT showed no association with ICU mortality (OR ATE: 1.08, 95%-CI 0.99-1.17; p=.08; OR ATT 1.09; 95%-CI 0.99-1.2; p=.09). Hazard ratios at 20-days (multivariable HR, matched sample n=348: 1.16, 95%-CI 0.86-1.56, p=.33) showed similar survival in the two study groups. We did not observe effects of SB infusion on all-cause mortality in critically ill patients with metabolic acidosis.

Effectiveness of implementing sepsis bundle of care on nurses' knowledge performance and ICU patient out comes

Background: Sepsis can cause severe degeneration in individuals it is vital to determined early. So important concern that can be addressed by critical care nurses' education is a lack of nursing competence and training about sepsis diagnoses. Aim: To evaluate effectiveness of implementing sepsis bundle of care on nurses' knowledge, performance, and ICU patient outcomes. Methods: Across-sectional correlational survey design was conduct in an intensive care unit, from 6 February 2022 to 29April 2022, study carry out in intensive care unit in Jizan hospitals. Conclusion: The study's results indicate that nurses' knowledge and practices about the sepsis bundle are insufficient in the intensive care unit's early days, but that when educational programs and policies were focused on, there was a significant improvement in the percentage of nurses' knowledge and practice. Recommendation: Provide Establish a new protocol that focuses triage and early detection of infection cases in emergency departments nurses with regular training sessions to help them succeed their sepsis bundle practices in critically ill patients.

Antimicrobial Stewardship during COVID-19 Outbreak: A Retrospective Analysis of Antibiotic Prescriptions in the ICU across COVID-19 Waves.

The demographics and outcomes of ICU patients admitted for a COVID-19 infection have been characterized in extensive reports, but little is known about antimicrobial stewardship for these patients. We designed this retrospective, observational study to investigate our hypothesis that the COVID-19 pandemic has disrupted antimicrobial stewardship practices and likely affected the rate of antibiotic de-escalation (ADE), patient outcomes, infection recurrence, and multidrug-resistant bacteria acquisition. We reviewed the prescription of antibiotics in three ICUs during the pandemic from March 2020 to December 2021. All COVID-19 patients with suspected or proven bacterial superinfections who received antibiotic treatment were included. The primary outcome was the rate of ADE, and secondary outcomes included the rate of appropriate empirical treatment, mortality rates and a comparison with a control group of infected patients before the COVID-19 pandemic. We included 170 COVID-19 patients who received antibiotic treatment for a suspected or proven superinfection, of whom 141 received an empirical treatment. For the latter, antibiotic treatment was de-escalated in 47 (33.3%) patients, escalated in 5 (3.5%) patients, and continued in 89 (63.1%) patients. The empirical antibiotic treatment was appropriate for 87.2% of cases. ICU, hospital, and day 28 and day 90 mortality rates were not associated with the antibiotic treatment strategy. The ADE rate was 52.2% in the control group and 27.6% in the COVID-19 group (p &lt; 0.001). Our data suggest that empirical antibiotic treatment was appropriate in most cases. The ADE rates were lower in the COVID-19 group than in the control group, suggesting that the stress associated with COVID-19 affected our practices.

Effects of sodium bicarbonate infusion on mortality in medical–surgical ICU patients with metabolic acidosis—A single-center propensity score matched analysis

ObjectiveMetabolic acidosis is associated with high mortality. Despite theoretical benefits of sodium-bicarbonate (SB), current evidence remains controversial. We investigated SB-related effects on outcomes in ICU patients with metabolic acidosis. DesignRetrospective analysis. SettingAcademic medical center. Patients or participants971 ICU patients with metabolic acidosis defined as arterial pH<7.3 and CO2<45mmHg treated between 2012 and 2016. A propensity score (PS) was estimated using logistic regression. Patients were matched in pairs using the PS. Interventions441 patients were treated with SB 8.4% (SB-group) and n=530 patients were not (control group). Main variables of interestPrimary outcome was all-cause mortality at ICU-discharge. Average Treatment Effect (ATE), Average Treatment effect in Treated (ATT), and estimated relative survival effects at 20 days were computed. ResultsIn the full cohort, we observed considerable differences in pH, base excess, additional acidosis-related indices, and ICU mortality (controls 31% vs. SB-group 56%, p<.001) at baseline between the two groups. After PS-matching (n=174 in each group), no significant difference in ICU mortality was observed (controls 32% vs. SB-group 41%; p=.07). Odds ratios (OR) for ATE and ATT showed no association with ICU mortality (OR ATE: 1.08, 95%-CI 0.99–1.17; p=.08; OR ATT 1.09; 95%-CI 0.99–1.2; p=.09). Hazard ratios at 20-days (multivariable HR, matched sample n=348: 1.16, 95%-CI 0.86–1.56, p=.33) showed similar survival in the two study groups. ConclusionsWe did not observe effects of SB infusion on all-cause mortality in critically ill patients with metabolic acidosis.

Association between type II diabetes mellitus and 90-day mortality in a large multicenter prospectively collected cohort. A FROG ICU post-hoc study

PurposeFactors associated with adverse outcomes in ICU patients with type II (T2DM) are poorly defined. The main goal of this study is to determine the impact of pre-existing T2DM on 90-day mortality post ICU admission. MaterialPost-hoc analysis from the FROG-ICU cohort. All patients admitted to ICU who were ventilated and/or treated by a vasoactive agent for >24 h were included.Association between T2DM and 90-day mortality was analyzed in unmatched, and populations matched by propensity score (PS) method to balance confounders recorded before ICU admission. Analysis was performed in non-imputed and imputed datasets. Results2002 patients were included, and 16% had a history of T2DM. The latter were at inclusion more severely ill (SAPSII score 51(39–67) vs 48(35–61), p < 0.0001; Charlson score 2(1–3) vs 0(0–2), p < 0.0001). In the unmatched cohort, T2DM patients had a higher 90-day risk of death compared to no-DM patients (HR 1.35(1.1–1.65)). The 90-day risk of death was not significantly different T2DM and no T2DM patients after PS matching (HR: 0.81 (0.56–1.18). Results were similar with the analysis performed on imputed datasets (pooled HR: 0.95 (0.69–1.30)). ConclusionsIn the present study, T2DM was not associated with 90-day mortality post ICU admission.

Sleep assessment in critically ill adults: A systematic review and meta-analysis.

To systematically review sleep evaluation, characterize sleep disruption, and explore effects of sleepdisruption on outcomes in adult ICU patients. We systematically searched databases from May 1969 to June 2021 (PROSPERO protocol number: CRD42020175581). Prospective and retrospective studies were included studying sleep in critically ill adults, excluding patients with sleep or psychiatric disorders. Meta-regression methods were applied when feasible. 132 studies (8797 patients) were included. Fifteen sleep assessment methods were identified, with only two validated. Patients had significant sleep disruption, with low sleep time, and low proportion of restorative rapid eye movement (REM). Sedation was associated with higher sleep efficiency and sleep time. Surgical versus medical patients had lower sleep quality. Patients on ventilation had a higher amount of light sleep. Meta-regression only suggested an association between total sleep time and occurrence of delirium (p < 0.001, 15 studies, 519 patients). Scarce data precluded further analyses. Sleep characterized with polysomnography (PSG) correlated well with actigraphy and Richards Campbell Sleep Questionnaire (RCSQ). Sleep in critically ill patients is severely disturbed, and actigraphy and RCSQ seem reliable alternatives to PSG. Future studies should evaluate impact of sleep disruption on outcomes.