Intermediate Care Unit Patients Research Articles

Amantadine for NeuroenhaNcement in acutE patients Study - a protocol for a prospective pilot proof of concept phase IIb study in intensive and intermediate care unit patients (ANNES)

BackgroundPersisting coma is a common complication in (neuro)intensive care in neurological disease such as acute ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage. Amantadine acts as a nicotinic receptor antagonist, dopamine receptor agonist and non-competitive N-Methyl-D-aspartate receptor antagonist. Amantadine is a long-known drug, originally approved for treatment of influenza A and Parkinson`s Disease. It has been proven effective in improving vigilance after traumatic brain injury. The underlying mechanisms remain largely unknown, albeit anti-glutamatergic and dopaminergic effects might be most relevant. With limited evidence of amantadine efficacy in non-traumatic pathologies, the aim of our study is to assess the effects of amantadine for neuroenhancement in non-traumatic neurointensive patients with persisting coma.MethodsAn investigator-initiated, monocenter, phase IIb proof of concept open-label pilot study will be carried out. Based on the Simon design, 43 adult (neuro)intensive care patients who meet the clinical criteria of persisting coma not otherwise explained and < 8 points on the Glasgow Coma Scale (GCS) will be recruited. Amantadine will be administered intravenously for five days at a dosage of 100 mg bid. The primary endpoint is an improvement of at least 3 points on the GCS. If participants present as non-responders (increase < 3 points or decrease on the GCS) within the first 48 h, the dosage will be doubled from day three to five. Secondary objectives aim to demonstrate that amantadine improves vigilance via alternative scales. Furthermore, the incidence of adverse events will be investigated and electroencephalography (EEG) will be recorded at baseline and end of treatment.DiscussionThe results of our study will help to systematically assess the clinical utility of amantadine for treatment of persisting coma in non-traumatic brain injury. We expect that, in the face of only moderate treatment risk, a relevant number of patients will benefit from amantadine medication by improved vigilance (GCS increase of at least 3 points) finally leading to a better rehabilitation potential and improved functional neurological outcome. Further, the EEG data will allow evaluation of brain network states in relation to vigilance and potentially outcome prediction in this study cohort.Trial RegistrationNCT05479032.

LIVING WITH MULTIMORBIDITY: SHARED EXPERIENCES OF PATIENTS, FAMILY CAREGIVERS, AND HEALTHCARE PROFESSIONALS

Abstract Over 50% of patients in intermediate care units (IMCU) present with multimorbidity, two or more chronic conditions. Balancing the effects of multimorbidity and their treatments with quality-of-life can be a challenge. This experience-based co-design project aimed to elicit experiences of patients, family caregivers, and healthcare professionals in IMCU, in the context of challenges and intricacies of multimorbidity management, to inform the development of a symptom management toolkit. Patients aged 55 years and older were recruited and interviewed in person. Healthcare professionals working in IMCU (i.e., physicians, nurses, respiratory therapists, social workers, etc.) were recruited and interviewed virtually. Participants were asked questions about their role in recognizing and treating symptoms, factors affecting quality of life, symptom burden and trajectory over time, and symptom management strategies that have and have not worked. An inductive thematic analysis approach was used for data analysis. Twenty-three interviews were conducted: 9 patients, 2 family-caregivers, and 12 healthcare professionals. Patients’ mean age was 67.5 (± 6.5) years, over half (n=5) were Black or Hispanic, and average number of multimorbidity was 3.67. Five major themes emerged: 1) importance of patient-provider relationship; 2) open and honest communication; 3) accessibility of resources during hospitalization and at discharge; 4) caregiver support, training, and education; and 5) care-coordination and follow-up care. Patients, caregivers, and healthcare professionals often have different priorities for multimorbidity management, treatment, and education. However, given the growing population of patients experiencing multimorbidity, it is imperative to identify shared priorities and target holistic interventions considering their experiences to enhance outcomes.

Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients

BackgroundIt is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients.MethodsRetrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria.ResultsSuspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71–0.72]; SOFA 0.52 [0.51–0.53]; qSOFA 0.82 [0.79–0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53–0.54]; SOFA 0.73 [0.70–0.77]; qSOFA 0.59 [0.58–0.59]).ConclusionsNone of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.

Impact of staffing a surgical intermediate care unit with a critical care specialist.

To assess the impact of reorganising an 11-bed surgical intermediate care unit (IMCU) from an open to a semi-closed system in a Swiss University Hospital by adding a critical care specialist (CCS). This was a cohort study including adult IMCU patients enrolled in an Enhanced Recovery After Surgery protocol in the Department of Visceral Surgery, Lausanne University Hospital, from 1 February 2014 to 31 January 2016. Medical supervision by a CCS was implemented on 1 February 2015. Introduction of a CCS in a surgical IMCU significantly reduced intensive care unit length of stay (p = 0.005) and potentially preventable operation (p = 0.04) for patients undergoing oesophageal surgery. A CCS in IMCU also proved to significantly reduce readmission in IMCU for hepatic surgery patients (p = 0.04). For other sub-specialties (colorectal, pancreatic and gastric bypass surgery) no significant difference could be found. Reorganisation of a surgical IMCU from an open to a semi-closed system by implementing supervision by a CCS decreased length of stay and complications for the most fragile surgical patients (oesophageal and hepatic patients) after 12 months of implementation.

The predictive performance of SAPS 2 and SAPS 3 in an intermediate care unit for internal medicine at a German university transplant center; A retrospective analysis.

ObjectiveTo analyze and compare the performance of the Simplified-Acute-Physiology-Score (SAPS) 2 and SAPS 3 among intermediate care patients with internal disorders.Materials and methodsWe conducted a retrospective single-center analysis in patients (n = 305) admitted to an intermediate-care-unit (ImCU) for internal medicine at the University Hospital Essen, Germany. We employed and compared the SAPS 2 vs. the SAPS 3 scoring system for the assessment of disease severity and prediction of mortality rates among patients admitted to the ImCU within an 18-month period. Both scores, which utilize parameters recorded at admission to the intensive-care-unit (ICU), represent the most widely applied scoring systems in European intensive care medicine. The area-under-the-receiver-operating-characteristic-curve (AUROC) was used to evaluate the SAPS 2 and SAPS 3 discrimination performance. Ultimately, standardized-mortality-ratios (SMRs) were calculated alongside their respective 95%-confidence-intervals (95% CI) in order to determine the observed-to-expected death ratio and calibration belt plots were generated to evaluate the SAPS 2 and SAPS 3 calibration performance.ResultsBoth scores provided acceptable discrimination performance, i.e., the AUROC was 0.71 (95% CI, 0.65–0.77) for SAPS 2 and 0.77 (95% CI, 0.72–0.82) for SAPS 3. Against the observed in-hospital mortality of 30.2%, SAPS 2 showed a weak performance with a predicted mortality of 17.4% and a SMR of 1.74 (95% CI, 1.38–2.09), especially in association with liver diseases and/or sepsis. SAPS 3 performed accurately, resulting in a predicted mortality of 29.9% and a SMR of 1.01 (95% CI, 0.8–1.21). Based on Calibration belt plots, SAPS 2 showed a poor calibration-performance especially in patients with low mortality risk (P<0.001), while SAPS 3 exhibited a highly accurate calibration performance (P = 0.906) across all risk levels.ConclusionsIn our study, the SAPS 3 exhibited high accuracy in prediction of mortality in ImCU patients with internal disorders. In contrast, the SAPS 2 underestimated mortality particularly in patients with liver diseases and sepsis.

Outcomes of prolonged mechanical ventilation in patients who underwent bedside percutaneous dilatation tracheostomy in intermediate care units- A single center study.

The number of chronic critical illness (CCI) patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, mandating health professionals to discuss interventions while considering disease trajectory. The aim of this study was to analyze the survival of CCI patients who underwent percutaneous dilatational tracheostomy (PDT) within intermediate care units. We carried out a retrospective study of all patients who underwent PDT in our intermediate care units from 2009 to 2015. Based on their survival statuses at different time points, patients were categorized into groups of survival at one week, one month, and one year following the procedure. This study included 254 patients. The mean age was 77.7 (±11.8) years. Out of the 254 patients included, 213 patients (84.2%) were defined as nursing care dependent. In-hospital mortality was 38.2% (97 patients). Seven patients (2.7%) were discharged to their homes. Overall survival rates at one week, one month, and one year following PDT were 88.6%, 66.1%, and 29.5%, respectively. Upon multivariate analyses, higher creatinine levels and resuscitation prior to the procedure were associated with increased mortality rates at one week and one month following tracheostomy. Higher creatinine and low albumin levels were associated with increased mortality at one year following tracheostomy. The prognosis of CCI patients in intermediate care units is generally poor. Identified risk factors for complications and survival should be presented to patients and their surrogates when discussing courses of action and future treatments.

Metabolomic state as early indicator of responsiveness to therapy in the acute phase of septic shock

Medical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur.To improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians.Among patients transferred from the IMCU to the MICU during baseline (n = 83;July–December 2012) and intervention phases (n = 94;July–December 2013), unadjusted mortality decreased from 34% to 21% (p = 0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11–0.98).Using a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Intermediate care to intensive care triage: A quality improvement project to reduce mortality

PurposeMedical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur. MethodsTo improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians. ResultsAmong patients transferred from the IMCU to the MICU during baseline (n=83;July–December 2012) and intervention phases (n=94;July–December 2013), unadjusted mortality decreased from 34% to 21% (p=0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11–0.98). ConclusionsUsing a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Clinical utility of a nasal swab methicillin-resistant Staphylococcus aureus polymerase chain reaction test in intensive and intermediate care unit patients with pneumonia

This retrospective study aimed to validate the concordance between nasal swab methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) test and respiratory culture and to determine the number of potentially preventable days of anti-MRSA therapy in patients with pneumonia. Two hundred adult inpatients in the intensive and intermediate care units were included. The nasal swab MRSA PCR test was positive in 55 (27.5%) patients. MRSA was isolated from respiratory culture in 21 (10.5%) patients. The nasal swab MRSA PCR test demonstrated 90.5% sensitivity, 79.9% specificity, 34.5% positive predictive value, and 98.6% negative predictive value. Anti-MRSA therapy was initiated in 168 (84%) patients. Patients in the study received a combined 782days of anti-MRSA therapy; 300days were considered potentially preventable. This study suggests that the nasal swab MRSA PCR test may be used to guide discontinuation of anti-MRSA antibiotics in patients with clinically confirmed pneumonia in the intensive or intermediate care units.

Novel Bedside Phonetic Evaluation to Identify Dysphagia and Aspiration Risk.

There is a need for improved clinical identification of hospitalized patients at risk of aspiration. We evaluated our novel phonetic test in a broad spectrum of patients at risk of aspiration in the ICU or intermediate care unit. We prospectively enrolled 60 hospitalized patients with aspiration risk, between December 2009 and September 2011, who subsequently underwent audio-recorded three-component phonetic bedside evaluation. The recordings were scored by two blinded speech-language pathologists. The institutional dysphagia admission screening test was performed by a bedside nurse. The primary outcomes, dysphagia and aspiration, were assessed by a videofluoroscopic swallowing study, fiber-optic endoscopic evaluation of swallowing, or both. We assessed the short- and long-term clinical outcomes (length of stay, subsequent aspiration pneumonia and respiratory failure, survival) and how these were associated with the phonetic and swallow assessments. Statistically significant linear associations with dysphagia were noted for all three individual phonetic components. Also, there were statistically significant linear associations with aspiration for diadochokinesis (P = .050) and consensus auditory-perceptual evaluation of voice (P = .025). Diadochokinesis alone predicted dysphagia (area under the curve [AUC], 0.74; P = .001) and aspiration (AUC, 0.67; P = .012). Its predictive ability improved when combined with normalized dysphagia admission screening test results (AUC, 0.79; P = .001). The short- and long-term clinical outcomes were adversely affected by the worse phonetic/swallowing scores, although they were not statistically different. Abnormal phonation among ICU and intermediate care unit patients is associated with dysphagia and aspiration. Future investigative efforts should uncover the most effective combination of evaluations for accurate bedside detection of dysphagia and aspiration risk in a broad spectrum of patients.

The effects of discharge to an intermediate care unit after a critical illness: A 5-year cohort study

PurposeThe impact of the intermediate care unit (IMCU) on post–intensive care unit (ICU) outcomes is controversial. Materials and MethodsWe analyzed admissions from January 2003 to December 2008 from a mixed ICU in a teaching hospital in Brazil with a high patient-to-nurse ratio (3.5:1 on the ICU, 11:1 on the IMCU, 20-25:1 on the ward). A retrospective propensity-matched analysis was performed with data from 690 patients who were discharged after at least 3 days of ICU stay. ResultsOf the 690 patients, 160 (23%) were discharged to the IMCU. A total of 399 propensity-matched patients were compared: 298 were discharged to the ward and 101 were discharged to the IMCU. Ninety-day mortality rate was similar between the IMCU and ward patients (22% vs 18%, respectively, P = .37), as was the unplanned ICU readmission rate (P = .63). In a multivariate logistic regression, discharge to the IMCU had no effect on the 90-day mortality rate (P = .27). ConclusionsIn a resource-limited setting with a high patient-to-nurse ratio, discharge to IMCU had no impact on 90-day mortality rate and on unplanned readmission rate. The impact of discharge to the IMCU on the outcome for critically ill patients should be evaluated in further studies.

Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings

Prolonged bed rest in hospitalized patients leads to deconditioning, impaired mobility, and the potential for longer hospital stays. The purpose of this study was to determine the effectiveness of a nurse-driven mobility protocol to increase the percentage of patients ambulating during the first 72 hours of their hospital stay. A quasi-experimental design was used before and after intervention in a 16-bed adult medical/surgical intensive care unit (ICU) and a 26-bed adult intermediate care unit (IMCU) at a large community hospital. A multidisciplinary team developed and implemented a mobility order set with an embedded algorithm to guide nursing assessment of mobility potential. Based on the assessments, the protocol empowers the nurse to consult physical therapists or occupational therapists when appropriate. Daily ambulation status reports were reviewed each morning to determine each patient's activity level. Retrospective and prospective chart reviews were performed to evaluate the effectiveness of the protocol for patients 18 years of age and older who were hospitalized 72 hours or longer. In the 3 months prior to implementation of the Move to Improve project, 6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patients ambulated during the first 72 hours of their hospitalization. During the 6 months following implementation, those rates rose to 20.2% (86 of 426) and 71.8% (257 of 358), respectively. The study was carried out at only one center. The initial experience with a nurse-driven mobility protocol suggests that the rate of patient ambulation in an adult ICU and IMCU during the first 72 hours of a hospital stay can be increased.

Prognostic factors of elderly patients admitted in a medical intermediate care unit

Introduction Population ageing has determined increased prevalence of chronic illness and functional impairment. Consequently, increased hospital admission of elderly patients is observed, not only in general wards but also in high dependency units such as medical intermediate care units (IntCU), despite uncertainty on their prognostic factors. Objective To identify prognostic factors of older patients admitted in an IntCU, namely acute illness severity, comorbidity and functional status. Design Prospective observational study. Setting IntCU of a Central and University Hospital. Subjects One hundred and seventy-six elderly patients consecutively admitted during 32 months, compared with 112 non-elderly patients. Main outcome measure IntCU mortality and In-hospital mortality. Methods At admission acute illness severity, comorbidity and previous functional status were measured. Outcome measurements included IntCU mortality and in-hospital mortality. Results Comorbidity and functional impairment were higher in elderly. Higher IntCU mortality in elderly patients (13.1%) was also observed as well as a higher in-hospital mortality. SAPS II was the best predictor of both IntCU and in-hospital mortality in elderly group. Charlson index was not a good predictor of IntCU and in-hospital mortality in elderly patients nor Barthel index a protective factor. Conclusions This study supports using SAPS II as the standard prognosis assessment tool of elderly admitted in IntCU. Despite Charlson and Barthel indexes were not associated with higher mortality in our study, a comprehensive assessment should be carried out when admitting elderly patients in IntCU, not being age the best criteria. Risk stratification is mandatory to predict benefit of IntCU admission and accurate tools need to be developed.

Short- and long-term outcomes of older patients in intermediate care units

Short- and long-term outcomes of older patients in intermediate care units

Short- and long-term outcomes of older patients in intermediate care units

To evaluate short- and long-term outcomes of elderly patients (>or=65 years) treated at an intermediate care unit (IMCU) and to identify outcome predictors. Prospective observational study in the IMCU of a university teaching hospital. We studied 412 patients over 8 months, classified into three groups: under 65years (control group, n=158), 65-80 (n=186), and >80 (n=68). At admission: APACHE II, TISS-28 first day, Charlson Index, diagnosis, and prior Barthel Index. in-hospital mortality, length of stay, discharge destination, and 2-year mortality and readmissions. Data analysis included multivariate logistic regression and receiver operating characteristics area under the curve (ROC AUC). No statistically significant differences between groups were observed in hospital mortality (14.1%), discharge to a long-term facility (2.7%), or 2-year readmissions (1.2+/-2.1). However, hospital stay was longer in patients aged 65-80years (14 vs.10 days) and 2-year mortality was higher in those 65 or over (34% vs.10.6%). In the overall series in-hospital mortality was predicted by APACHE II, first-day TISS-28, and diagnosis (ROC AUC 0.81), and 2-year mortality by Charlson Index and age (ROC AUC 0.77). In the elderly patients 2-year mortality was predicted by Charlson and Barthel indices (ROC AUC 0.70). Illness severity and therapeutic intervention at admission to IMCU were predictors of short-term mortality, whereas the strongest predictor of long-term mortality was comorbidity. Our results suggest that comprehensive assessment of elderly patients at admission to IMCUs may improve outcome prediction.