Reduced Hospital Mortality Research Articles

Aortic valve surgery in the UK, trends in activity and outcomes from a 15-year complete national series.

Since the turn of the century, cardiac surgery has evolved quite notably. This study sought to investigate the trends in aortic valve surgery activity and subsequent outcomes in the UK by using a mandatory national cardiac surgical clinical database within the context of a comprehensive public healthcare system (National Health Service). The UK National Adult Cardiac Surgery Audit database provided data for aortic valve surgery procedures performed between 2002 and 2016, and the data were validated and cleaned using reproducible algorithms. The findings and trends in in activity and outcomes were then analysed by financial year. During the study period, a total of 148 862 procedures were performed, with the number of cases per year peaking in 2014/2015 at 12 483. The mean in-hospital mortality rate for all aortic valve surgery has fallen from 5.6% to 3.4%, despite an increase in patient age and mean logistic EuroSCORE. While the number of isolated aortic valve replacements has remained stable at around 5000 per year, aortic valve replacement and coronary artery bypass graft have increased to over 3200 with transcatheter aortic valve implantation activity continuing to increase. This study demonstrates that despite an increase in patient risk profile, there has been a consistent reduction in in-hospital mortality within all aortic valve surgery procedures performed in the UK over a 15-year period. Increasing catheter-based interventions have not yet resulted in a significant decrease in surgical aortic valve replacements in the UK.

Limited utility of the HScore in detecting secondary haemophagocytic lymphohistiocytosis in COVID‐19

Limited utility of the HScore in detecting secondary haemophagocytic lymphohistiocytosis in COVID‐19

Changes in in-hospital mortality in the first wave of COVID-19: a multicentre prospective observational cohort study using the WHO Clinical Characterisation Protocol UK

SummaryBackgroundMortality rates in hospitalised patients with COVID-19 in the UK appeared to decline during the first wave of the pandemic. We aimed to quantify potential drivers of this change and identify groups of patients who remain at high risk of dying in hospital.MethodsIn this multicentre prospective observational cohort study, the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK recruited a prospective cohort of patients with COVID-19 admitted to 247 acute hospitals in England, Scotland, and Wales during the first wave of the pandemic (between March 9 and Aug 2, 2020). We included all patients aged 18 years and older with clinical signs and symptoms of COVID-19 or confirmed COVID-19 (by RT-PCR test) from assumed community-acquired infection. We did a three-way decomposition mediation analysis using natural effects models to explore associations between week of admission and in-hospital mortality, adjusting for confounders (demographics, comorbidities, and severity of illness) and quantifying potential mediators (level of respiratory support and steroid treatment). The primary outcome was weekly in-hospital mortality at 28 days, defined as the proportion of patients who had died within 28 days of admission of all patients admitted in the observed week, and it was assessed in all patients with an outcome. This study is registered with the ISRCTN Registry, ISRCTN66726260.FindingsBetween March 9, and Aug 2, 2020, we recruited 80 713 patients, of whom 63 972 were eligible and included in the study. Unadjusted weekly in-hospital mortality declined from 32·3% (95% CI 31·8–32·7) in March 9 to April 26, 2020, to 16·4% (15·0–17·8) in June 15 to Aug 2, 2020. Reductions in mortality were observed in all age groups, in all ethnic groups, for both sexes, and in patients with and without comorbidities. After adjustment, there was a 32% reduction in the risk of mortality per 7-week period (odds ratio [OR] 0·68 [95% CI 0·65–0·71]). The higher proportions of patients with severe disease and comorbidities earlier in the first wave (March and April) than in June and July accounted for 10·2% of this reduction. The use of respiratory support changed during the first wave, with gradually increased use of non-invasive ventilation over the first wave. Changes in respiratory support and use of steroids accounted for 22·2%, OR 0·95 (0·94–0·95) of the reduction in in-hospital mortality.InterpretationThe reduction in in-hospital mortality in patients with COVID-19 during the first wave in the UK was partly accounted for by changes in the case-mix and illness severity. A significant reduction in in-hospital mortality was associated with differences in respiratory support and critical care use, which could partly reflect accrual of clinical knowledge. The remaining improvement in in-hospital mortality is not explained by these factors, and could be associated with changes in community behaviour, inoculum dose, and hospital capacity strain.FundingNational Institute for Health Research and the Medical Research Council.

In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience.

In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

Reduction of Inhospital Mortality of Patient Admissions to Cardiac Intensive Care Units During the COVID-19 Pandemic in Hunan, China.

This study aims to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on patient admissions to Hunan's cardiac intensive care units (CCUs).We conducted a retrospective, single-center study. Data were collected from patients who were confirmed to have critical cardiovascular disease and admitted to the CCU of the Second Xiangya Hospital of Central South University, Hunan, from January 23 to April 23, 2020. Compared with the same period in 2019, the results show that the number of hospitalization decreased by 19.6%; the inhospital mortality rate of CCU was decreased (28.57% versus 16.67%; odds ratio (OR), 0.50; 95% confidence interval (CI), 0.251-0.996; P = 0.047); hospital stay was decreased (7.97 versus 12.36, P < 0.001); hospital emergency percutaneous coronary intervention (PCI) rate in patients with acute coronary syndromes (ACS) significantly decreased (76.00% versus 39.00%, P < 0.001); among this, the PCI rate of patients with ST-segment elevation myocardial infarction (STEMI) decreased (76.32% versus 55.17%, P = 0.028) as well. In addition, the number of patients transferred from other hospitals significantly decreased (76.79% versus 56.67%, P = 0.002), and the number of patients transferred from other cities also decreased by 10.75%.During the outbreak of the COVID-19 epidemic in Hunan Province, the number of patients admitted to CCU decreased, as well as the mortality rate; fewer patients with severe cardiovascular disease can be transported to better hospitals from remote rural areas. In addition to epidemic prevention and control, experts in China should focus on improved emergency transport medical services to reduce this impact.

Impact of Severe Pulmonary Hypertension on Cardiac Surgery Today

Objective: Severe pulmonary hypertension is a poor prognostic factor in cardiac surgery. However, advances in surgery, anesthesia and postoperative care, as well as a better understanding of the pathophysiology of pulmonary hypertension, make it possible to offer surgery to more patients in this situation. We present a series of consecutive heart-operated Molinpatients with severe pulmonary hypertension in order to know their hospital evolution, follow-up and check if, after the intervention, the pulmonary hypertension reverts. Methods: Retrospective descriptive study on a heart operated patient with severe PHT between 2016 and 2019 in a third-level hospital in Murcia. Sociodemographic, surgical and follow-up characteristics were analyzed during the period described above. Continuous variables expressed as median and IQR or mean and standard deviation. Qualitative variables expressed percentages. Results: Between 2016 and 2019, 69 patients with severe pulmonary hypertension underwent surgery at our center. Mean age of 68.3 ± 11 years, 54% women, 45% in Atrial Fibrillation, 22% urgent. Preoperative functional grade 2.5 ± 0.6 of the NYHA. 57% were operated from a single valve, 30% from two or more valves. They spent a median of 2 (1-3.5) days in the ICU and 11 (7-18) days in the hospital. Eight patients (11.6%) died on admission. No patient treated with nitric oxide (7%) in the operating room died. Median follow-up 16 (7.5-25.5) months. Mortality in follow-up 5%. Survival at 30 months of 94%. At follow-up, 48% had moderate pulmonary hypertension, 26% mild, and 26% severe pulmonary hypertension. Functional grade at follow-up 1.6 ± 0.5 of the NYHA. Conclusions: Severe pulmonary hypertension is still associated with high hospital mortality in cardiac surgery, but in the medium-long term it presents good survival and functional grade. Perhaps an earlier indication of the intervention and the use of nitric oxide in the operating room could help reduce hospital mortality.

Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

Leading predictors of early and late hospital mortality among patients with acute decompensated heart failure and ways to improve prognosis

Objective: to analyze the leading causes of early (first two days) and late (after the second day) hospital mortality among of patients with acute decompensated heart failure.Materials and methods: a retrospective single-center cohort (n=718) of patients with acute decompensated heart failure.Results: predictors of prognosis for early hospital mortality were pulmonary edema, hepatomegaly, the need for inotropic and vasopressive drugs, the level of systolic blood pressure and creatinine. Predictors of prognosis for late hospital mortality were pulmonary edema, the need for inotropic drugs, community-acquired pneumonia, and laboratory markers of acute renal injury.Conclusion: Tactical approaches are proposed to reduce hospital mortality of patients with acute decompensated heart failure.

Efficacy and Safety of Tranexamic Acid in Emergency Trauma: A Systematic Review and Meta-Analysis.

In trauma patients, bleeding can lead to coagulopathy, hemorrhagic shock, and multiorgan failure, and therefore is of fundamental significance in regard to early morbidity. We conducted a meta-analysis to evaluate the efficacy and safety of tranexamic acid (TXA) in civil and military settings and its impact on in-hospital mortality (survival to hospital discharge or 30-day survival), intensive care unit and hospital length of stay, incidence of adverse events (myocardial infarct and neurological complications), and volume of blood product transfusion. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic review of the literature using PubMed, Scopus, EMBASE, Web of Science, and the Cochrane Central Register and Controlled Trials (CENTRAL) database was conducted from inception to 10 January 2021. In-hospital mortality was reported in 14 studies and was 15.5% for the TXA group as compared with 16.4% for the non-TXA group (OR = 0.81, 95% CI 0.62–1.06, I2 = 83%, p = 0.12). In a civilian TXA application, in-hospital mortality in the TXA and non-TXA groups amounted to 15.0% and 17.1%, respectively (OR = 0.69, 95% CI 0.51–0.93, p = 0.02, I2 = 78%). A subgroup analysis of the randomized control trial (RCT) studies showed a statistically significant reduction in in-hospital mortality in the TXA group (14.3%) as compared with the non-TXA group (15.7%, OR = 0.89, 95% CI 0.83–0.96, p = 0.003, I2 = 0%). To summarize, TXA used in civilian application reduces in-hospital mortality. Application of TXA is beneficial for severely injured patients who undergoing shock and require massive blood transfusions. Patients who undergo treatment with TXA should be monitored for clinical signs of thromboembolism, since TXA is a standalone risk factor of a thromboembolic event and the D-dimers in traumatic patients are almost always elevated.

Abstract P437: Trends in Outcomes, and Length and Costs of Hospitalization in Patients With Intracerebral Hemorrhage in United States

Background: It remains unclear whether there is any improvement in outcomes of patients with intracerebral hemorrhage over the last decade. Objective: To determine trends pertaining in-hospital outcomes in patients with intracerebral hemorrhage using nationally representative data. Methods: We determined the national estimates of intracerebral hemorrhage admissions from 2005 to 2014 and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. Outcome was classified as none to minimal disability, moderate to severe disability, and death based on discharge destination. Results: In the 10-year period, there were 70,637 admissions for intracerebral hemorrhage (annual estimate 80804 in 2005 to 109930 in 2014). There was a significant reduction in in-hospital mortality in patients with intracerebral hemorrhage from 30% to 23% (trend test, p &lt; 0.0001). There was a trend towards increase in proportion of patients with moderate to severe disability (trend test, p &lt; 0.097). The mean length of hospitalization increased from 8.58 days to 9.23 days (trend test, p &lt; 0.0001) and cost of hospitalization increased from $50532.1 to $110932.1 (trend test, p &lt; 0.0001). Conclusions: The mortality in patients with intracerebral hemorrhage has decreased but there is increased rates of moderate to severe disability, length of hospitalization, and hospitalization cost over the last decade.

Antiviral Abidol is Associated with the Reduction of In-Hospital Mortality in COVID-19 Patients.

Objective:Coronavirus disease 2019 (COVID-19) is a global public health crisis. There are no specific antiviral agents for the treatment of SARS-CoV-2. Information regarding the effect of Abidol on in-hospital mortality is scarce. The present study aimed to evaluate the treatment effect of Abidol for patients with COVID-19 before and after propensity score matching (PSM).Methods:This retrospective cohort study analyzed 1019 patients with confirmed COVID-19 in China from December 22, 2019 to March 13, 2020. Patients were divided to Abidol (200 mg, tid, 5–7 days, n = 788, 77.3%) and No-Abidol (n = 231, 22.7%) groups. The primary outcome was the mortality during hospitalization.Results:Among 1019 COVID-19 patients, the age was (60.4 ± 14.5) years. Abidol-treated patients, compared with No-Abidol-treated patients, had a shorter duration from onset of symptoms to admission, less frequent renal dysfunction, lower white blood cell counts (lymphocytes <0.8) and erythrocyte sending rate, lower interleukin-6, higher platelet counts and plasma IgG and oxygen saturation, and less frequent myocardial injury. The mortality during hospitalization before PSM was 17.9% in Abidol group and 34.6% in No-Abidol (hazard ratio (HR) = 2.610, 95% confident interval (CI): 1.980–3.440), all seen in severe and critical patients. After PSM, the in-hospital death was 13.6% in Abidol and 28.6% in No-Abidol group (HR = 2.728, 95% CI: 1.598–4.659).Conclusions:Abidol-treatment results in less in-hospital death for severe and critical patients with COVID-19. Further randomized study is warranted to confirm the findings from this study.

Cancer patients in the intensive care unit

Over the past 20 years, demographic changes and a longer life expectancy of cancer patients has significantly increased the prevalence of this patient group in the intensive care unit (ICU). A fundamental finding is that acute organ dysfunction, rather than the underlying malignancy, determines the prognosis of ICU patients. While hematologic patients often suffer from a more severe disease course, patients with solid tumors do not present an increased hospital mortality compared to the normal population. As with other indications, the decision to transfer a cancer patient to an ICU should be made as soon as possible. While early transfer is associated with reduced hospital mortality, the presence of multiorgan failure on ICU admission is associated with increased mortality. Overall, the intensive care and hospital survival of critically ill hematologic or oncologic patients has improved over the last two decades and is now as high as 50 to 60%. After surviving an intensive care stay, one fifth of all patients have a good long-term prognosis. Thus, the former paradigm of general rejection of cancer patients for ICU care is no longer justified. For optimal care of cancer patients requiring intensive care, close cooperation between hematologists/oncologists and intensive care physicians is essential.

Trends and outcomes for cardiac surgery in the United Kingdom from 2002 to 2016

ObjectivesCardiac surgery has evolved significantly since the turn of the century. The objective of this study was to investigate trends in cardiac surgery activity and outcomes in the United Kingdom utilizing a mandatory national cardiac surgical clinical database in the context of a comprehensive public health care system (ie, the UK National Health Service). MethodsData for all cardiac surgery procedures performed between 2002 and 2016 were extracted from the UK National Adult Cardiac Surgery Audit database. Data are validated and cleaned using reproducible algorithms. Trends in activity and outcomes were analyzed by fiscal year using linear regression. ResultsA total of 534,067 procedures were performed during the study period with the number of cases per year peaking in 2008/2009 at 41,426. Despite an increase in patient age and mean logistic European System for Cardiac Operative Risk Evaluation score, the in-hospital mortality rate for all cardiac surgery has fallen from 4.0% to 2.8% (P < .001). The number of isolated coronary artery bypass graft procedures has steadily declined but the total number of valve procedures has steadily increased (both P values < .001). The number of thoracic aortic procedures performed each year has doubled (P < .001), but the incidence of redo procedures has steadily declined. The proportion of emergency and salvage procedures has remained stable. ConclusionsThis study, which covers all cardiac surgery procedures performed in the United Kingdom for fiscal years between 2002 and 2016, demonstrates that despite an increase in patient risk profile, there has been a consistent reduction in in-hospital mortality. A number of other markers associated with quality have also improved.

The effect of mild hypercapnia on hospital mortality after cardiac arrest may be modified by chronic obstructive pulmonary disease.

The main objective was to evaluate the effect of carbon dioxide on hospital mortality in chronic obstructive pulmonary disease (COPD) and non-COPD patients with out-of-hospital cardiac arrest (OHCA). We conducted a retrospective observational study in OHCA patients from the eICU database (eicu-crd.mit.edu). The main exposure was the partial pressure of arterial carbon dioxide (PaCO2). The proportion of time spent (PTS) within four predefined PaCO2 ranges (hypocapnia: <35mmHg, normocapnia: 35-45mmHg, mild hypercapnia: 46-55mmHg, and severe hypercapnia: >55mmHg) were calculated respectively. The primary outcome was hospital mortality. Multivariable logistic regression models were performed to assess the independent relationship between PTS within PaCO2 range and hospital mortality, and the interaction between PTS within PaCO2 range and COPD was explored. A total of 1721 OHCA patients were included, of which 272 (15.8%) had COPD. After adjusted for the confounders, the PTS within mild hypercapnia was associated with lower odds ratio for hospital mortality in COPD patients (OR 0.923; 95% CI 0.857-0.992; P=0.036); however, it was associated with higher odds ratio for hospital mortality in non-COPD patients (OR 1.053; 95% CI 1.012-1.097; P=0.012; Pinteraction=0.008). The PTS within normocapnia was not associated with hospital mortality in COPD patients (OR 0.987; 95% CI 0.914-1.067; P=0.739); however, it was associated with lower odds ratio for hospital mortality in non-COPD patients (OR 0.944; 95% CI 0.916-0.973; P<0.001; Pinteraction=0.113). The effect of carbon dioxide on hospital mortality differed between COPD and non-COPD patients. Mild hypercapnia was associated with increased hospital mortality for non-COPD patients but reduced hospital mortality for COPD patients. It would be reasonable to adjust PaCO2 targets in OHCA patients with COPD.

Effect of continuous blood purification for acute renal injury after acute Stanford type A aortic dissection

Objective: To investigate the effect of continuous renal replacement therapy (CRRT) on acute kidney injury (AKI) after acute Stanford type A aortic dissection (ATTAD). Methods: In this study, 120 patients with AKI after ATTAD surgery treat in Gansu Provincial People's Hospital were selected as research objects. Among them, there were 86 males (71.7%) and 34 females (28.3%) with a mean age of (55±5) years. These patients were randomly divided into experimental group (n=60) and control group (n=60) with stratified random sampling. CRRT and intermittent hemodialysis (IHD) were performed in the experimental group and the control group respectively. The therapeutic effect of CRRT on ATTAD patients with AKI was evaluated by blood purification index, renal function index, Sequential Organ Failure Assessment (SOFA) score, inflammatory level, hemodynamic index and fluid infusion volume. Results: The two treatment schemes both had considerable therapeutic effects on the condition of patients, but the therapeutic effect of CRRT was more superior. In the patients treated with CRRT, the levels of serium creatinine (SCr), blood urea nitrogen (BUN) and blood lactic acid (Lac) were all lower than those in the control group (all P<0.05). The time of staying in intensive care units (ICU), the period of oliguria, the times of renal replacement therapy, the time from the first dialysis to the last dialysis and the total hospital stay in the experimental group were all shorter than those in the control group (all P<0.05). The volume of fluid infusion was less and the hemodynamic index was better than that in the control group, but there was no significant difference in hospital mortality between the two groups (P>0.05). The levels of interleukin (IL)-6, IL-8 and C-reactive protein (CRP) in the experimental group were (21.9±1.8) ng/L, (18.6±1.4) ng/L and (22.7±2.2) mg/L, respectively, which were all significantly lower than those in control group ((27.9±3.2) ng/L, (28.3±1.4) ng/L, (60.1±2.5)mg/L, respectively; t=14.527, 13.255, 11.247, all P<0.05). The scores of SOFA at all time points in the experimental group were all lower than those in the control group (all P<0.05). Conclusion: Compared with IHD, CRRT brings no significant reduction in hospital mortality in patients with AKI after ATTAD, but shows better prognosis.

Glutamine on critical-ill patients: a systematic review and meta-analysis.

To conduct a meta-analysis of the effect of glutamine supplements on prognosis in adult critical-ill patients. We searched the Web of Science, Cochrane library, PubMed, the Wanfang Database, and the China National Knowledge Infrastructure (CNKI)/CBMdisc database. The primary outcome was hospital mortality, or if not reported, 28-day/6-month/intensive care unit (ICU) mortality. The secondary outcomes were duration of mechanical ventilation (MV), length of stay (LOS) in the ICU, LOS in the hospital, and nosocomial infections. In 599 related articles, 47 randomized controlled trials, including 6,198 patients, met all the inclusion criteria. Hospital mortality was not significantly different between the glutamine group and the control group. Length of MV was significantly higher in the control group than that of the glutamine group. In a subgroup analysis of severely burned patients, hospital mortality had the same trend. In other subgroups, there was no significant difference between the two groups. We suggest that supplemental glutamine need not be routinely added to the diet of criticalill patients to reduce hospital mortality, with the exception of the diet of severely burned patients.

Anticoagulation in COVID-19: a single-center retrospective study

ABSTRACT Introduction: COVID-19 induces a pro-thrombotic state as evidenced by microvascular thrombi in the renal and pulmonary vasculature. Therapeutic anticoagulation in COVID-19 has been debated and data remain anecdotal. Hypothesis: We hypothesize that therapeutic anticoagulation is associated with a reduction in in-hospital mortality, upgrade to intensive care unit, invasive mechanical ventilation, and acute renal failure necessitating dialysis by decreasing the over-all clot burden. Methods: A retrospective cohort study was done to determine the impact of therapeutic anticoagulation in hospitalized COVID-19 patients. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI) respectively. Results: A total of 176 hospitalized COVID-19 patients were divided into two groups, therapeutic anticoagulation and prophylactic anticoagulation. The mean age, baseline comorbidities and other medications used during hospitalization were similar in both groups. The aOR for in-hospital mortality (OR 3.05, 95% CI 1.15–8.10, p = 0.04), upgrade to intensive care (OR 3.08, 95% CI 1.43–6.64, p = 0.006) and invasive mechanical ventilation (OR 4.27, 95% CI 1.95–9.34, p = 0.00) were significantly lower while there was no statistically significant difference in the rate of developing acute renal failure (OR 1.87 95% CI 0.46–7.63, p = 0.64) between two groups. Conclusions: In patients with COVID-19, therapeutic anticoagulation offers a significant reduction in the rate of in-hospital mortality, upgrade to intensive medical care, and invasive mechanical ventilation. It should be preferred over prophylactic anticoagulation in COVID-19 patients unless randomized controlled trials prove otherwise.

10. The Impact of the Verigene® Gram-positive Blood Culture Panel on the Management of Vancomycin Resistant enterococci Bloodstream Infections in a Multi-site Cohort Study

BackgroundVancomycin-resistant Enterococcus (VRE) bloodstream infections (BSIs) are associated with high morbidity and mortality. PCR-based rapid diagnostic tests provide prompt identification of infectious etiologies within hours. This study evaluated the impact of the Verigene® Gram-positive blood culture (GP-BC) panel on the outcomes on patients with VRE BSIs.MethodsA multi-center pre- and post-implementation retrospective cohort study was conducted at four large HCA Healthcare facilities. The implementation of Verigene® GP-BC and VigiLanz® surveillance software with real-time notifications to clinical pharmacists occurred in 2015. Adults > 18 years with VRE BSIs were evaluated over two time periods; pre-implementation (Pre; May 2011 - May 2013) and post-implementation (Post; May 2015 - May 2017). Patients were excluded if not admitted or were discharged/deceased before blood culture results. The primary outcome of this study was to compare time to optimal therapy (TOT). Secondary outcomes included hospital mortality, length of stay (LOS), and TOT comparing clinical pharmacy staffing models. Multivariable logistic regression models were used to identify independent predictors. Adjusted ORs (aOR) and their 95% CIs were reported.ResultsA total of 104 patients with VRE BSIs were included in the study; 50 and 54 in the pre- and post-implementation periods, respectively. There were no differences in baseline characteristics between the groups. TOT was significantly shorter in the post vs. pre group (29 hrs ± 36 vs. 67 hrs ± 124, p=0.03). There was significantly lower hospital mortality when comparing the pre- and post-implementation periods (32% vs. 11%, p< 0.01). After adjusting for age, sex, severity of illness, treatment/dose, the post implementation period was independently associated with reduced hospital mortality (aOR 0.21, CI 0.61–0.73, p=0.01). There were no significant differences in LOS or clinical pharmacy staffing models on TOT.Baseline Characteristics Primary and secondary outcomes data ConclusionThe implementation of the Verigene® BC-GP with VigiLanz® substantially decreased TOT for VRE BSIs and was associated with reduced hospital mortality. This study highlights the positive impact of RDTs on shorter TOT and associated clinical outcomes.Disclosures All Authors: No reported disclosures

Airway pressure release ventilation versus low tidal volume ventilation for patients with acute respiratory distress syndrome/acute lung injury: a meta-analysis of randomized clinical trials.

BackgroundIt is uncertain whether airway pressure release ventilation (APRV) is better than low tidal volume ventilation (LTVV) for patients with acute respiratory distress syndrome (ARDS). The purpose of this meta-analysis was to compare APRV and LTVV on patients with ARDS.MethodsRandomized controlled trials (RCTs) comparing outcomes in ARDS ventilator therapy with APRV or LTVV were identified using Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, the Cochrane Library, and The Chinese Biomedicine Literature Database (SinoMed) from inception to March 2019.ResultsA total of 7 RCTs with a 405 patients were eligible for our meta-analysis. The results revealed that APRV was associated with lower hospital mortality [405 patients; odds ratio (OR), 0.57; 95% confidence interval (CI), 0.37–0.88; P=0.01], a shorter time of ventilator therapy [373 patients; mean difference (MD), 5.36; 95% CI, 1.99–8.73; P=0.002], and intensive care unit (ICU) stay (315 patients; MD, −4.50; 95% CI, −6.56 to −2.44; P<0.0001), better respiratory system compliance on day 3 (202 patients; MD, 8.19; 95% CI, 0.84–15.54; P=0.03), arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) on day 3 (294 patients; MD, 44.40; 95% CI, 16.05–72.76; P=0.002), and higher mean arterial pressure (MAP) on day 3 (285 patients; MD, 4.18; 95% CI, 3.10–5.25; P<0.00001). There was no statistical difference in the incidence of pneumothorax (170 patients; OR, 0.40; 95% CI, 0.12–1.34; P=0.14).ConclusionsThe meta-analysis showed that APRV could reduce hospital mortality, duration of ventilation and ICU stay, improve lung compliance, oxygenation index, and MAP compared with LTVV for patients with ARDS. We found APRV to be a safe and effective ventilation mode for patients with ARDS.

Abstract 319: A Multi-faceted Programmatic Approach Associated with Over 50% Reduction in In-hospital Mortality

Introduction: In the United States, the chance of dying in the hospital widely varies by hospital, with bottom-decile hospitals having twice the rates of risk-adjusted mortality when compared to top-decile hospitals. This suggests a need for improvement in health systems nationwide. Here, we describe the implementation of, and associated outcomes for a multi-faceted, evidence-based approach to reducing in-hospital mortality. Methods: This is a retrospective interrupted time-series conducted at a large, urban, academic health system. Specifically, we describe the implementation of the following evidence-based methods: 1) escalation of communication guidelines, 2) proactive rounding with nurse response teams, and 3) rapid response teams with dedicated staff. We then quantify the associated observed-to-expected (O:E) in-hospital mortality over a 12-year period at our main hospital, and subsequently over a 3-year period at an affiliated hospital where the same interventions were later implemented. Results: Over 12 years, 445,308 patients were discharged from our main hospital, with 3,948 (0.9%) being discharged to an acute care facility, 4,558 (1.0%) discharged to hospice, and 4,648 (1.0%) expiring in the hospital. Patients had an average age of 53.1 years (std.dev 22.8 years), with the majority being female (59.0%), non-Hispanic white (66.1%), and admitted from the outpatient setting (93.3%). From the years 2010 to 2013, there was decline in O:E mortality by 59.0% (Figure 1A). This effect was sustained from 2014-2018. At the affiliate hospital, there was a similar decline in O:E mortality after implementation of the same interventions (60.5%, Figure 1B). Conclusion: Our multi-faceted, programmatic approach was associated with over 50% reductions in in-hospital mortality that were sustained for several years after implementation, and were reproduced at an affiliated hospital.