Require ICU-level Care Research Articles

Is Everyone Beating Around the Bush?: A Qualitative Study Examining the Status of Shared Decision-Making Between Veterans Affairs Providers and Surgical Patients in the ICU.

We sought to determine if and how providers use elements of shared decision-making (SDM) in the care of surgical patients in the intensive care unit (ICU). SDM is the gold standard for decision-making in the ICU. However, it is unknown if this communication style is used in caring for critically ill surgical patients. Qualitative interviews were conducted with providers who provide ICU-level care to surgical patients in Veterans Affairs hospitals. Interviews were designed to examine end-of-life care among veterans who have undergone surgery and require ICU-level care. Forty-eight providers across 14 Veterans Affairs hospitals were interviewed. These participants were diverse with respect to age, race, and sex. Participant dialogue was deductively mapped into 8 established SDM components: describing treatment options; determining roles in the decision-making process; fostering partnerships; health care professional preferences; learning about the patient; patient preferences; supporting the decision-making process; and tailoring the information. Within these components, participants shared preferred tools and tactics used to satisfy a given SDM component. Participants also noted numerous barriers to achieving SDM among surgical patients. Providers use elements of SDM when caring for critically ill surgical patients. Additionally, this work identifies facilitators that can be leveraged and barriers that can be addressed to facilitate better communication and decision-making through SDM. These findings are of value for future interventions that seek to enhance SDM among surgical patients both in the ICU and in other settings.

Abstract 15794: Incidence & Complications of Myocarditis in US Active-Duty Service Members Hospitalized With COVID-19 Infection

Introduction: Cardiovascular complications of coronavirus disease 2019 (COVID-19) infection, including myocarditis, have been widely reported. Research question/hypothesis: What was the incidence and clinical implications of viral myocarditis resulting from COVID-19 infection in hospitalized United States active-duty service members (US ADSM)? Goal/aims: Report the incidence of complications in US ADSM who suffered COVID-19 associated myocarditis. Methods: This retrospective observational cohort study from the Joint Trauma Service COVID-19 Registry included 399,284 US ADSM who contracted COVID-19 infection. Our team independently reviewed records of hospitalized US ADSM who were determined to have COVID-19 associated myocarditis. Results: Among the 399,284 US ADSM who contracted COVID-19, 1,629 (0.4%) required hospitalization and 18 (1.1%) met criteria for myocarditis. The most common presenting symptoms were chest pain (72%) and dyspnea (67%). Half of the patients required ICU level care of which 44% required inotropes or vasopressors, and one patient required mechanical circulatory support. Eight (44%) patients had clinical findings consistent with acute heart failure and two (11%) patients suffered intermittent advanced heart block that did not require permanent pacing. No patients died in the hospital. In the patients who had a left ventricular ejection fraction of less than 50% during their illness, 75% had full recovery of their left ventricular systolic function during follow up imaging. Conclusions: While myocarditis was an uncommon complication in US ADSM hospitalized for COVID-19, its clinical course was not benign.

Baricitinib or Tocilizumab? Treatment of Patients Hospitalized With Severe COVID-19.

Baricitinib or Tocilizumab? Treatment of Patients Hospitalized With Severe COVID-19.

34: COMPARISON OF STRAIN AND CONVENTIONAL ECHOCARDIOGRAPHY IN PREDICTING ICU NEEDS IN MIS-C

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) after SARS-CoV-2 infection is often complicated by ventricular dysfunction. Our prior work suggests that strain echocardiography (SE) detects abnormalities in cardiac function in ICU patients unrecognized by conventional echocardiography (CE). This study compares the relative strengths of CE and SE in predicting needs for ICU level therapies in MIS-C patients. Methods: A retrospective, single center analysis was performed on patients admitted to a quaternary-care children’s hospital with the diagnosis of MIS-C from March 2020 to January 2022. Only patients with CE and SE measured prior to initiation of vasoactives were included. Abnormal LVEF was defined as < 55% and abnormal strain as <= -17.2%. Clinical metrics included use of positive pressure ventilation (PPV), vasoactives, or any ICU level care. Results: Of 90 patients diagnosed with MIS-C, median LVEF was normal in both normal (64.0%) and abnormal strain (57.2%) groups. We found 97.6% of patients with normal strain had normal LVEF but only 57.1% of those with normal LVEF had normal strain. Median LVEF was normal in both those who did and did not require ICU level care (63% vs 57.1%), and those who did and did not require vasoactives (62.4% vs 56.5%). Strain was abnormal in patients who required ICU level care, PPV, and vasoactives (-13.8%, -12.9%, -13.8% respectively), compared to those who did not (all -19.3%, p all < 0.001). Sensitivity analysis showed strain was superior to LVEF in identifying need for ICU level care (75.8% vs 39%), PPV (88% vs 48%), and vasoactives (90% vs 55%). Negative predictive value of strain was superior to LVEF for similar outcomes (ICU level care (80.9% vs 72%), PPV (92.7% vs 81.9%) and vasoactives (95.1% vs 87.2%)). Conclusions: We demonstrate that SE detects abnormalities in cardiac function in MIS-C patients unrecognized by CE. In both ICU and non-ICU patients, we found compared to LVEF, detection of abnormal strain better identifies patients who will need ICU level therapies. Similarly, a measurement of normal strain is superior to a normal LVEF in predicting those who will not need these interventions.

9: IMPLEMENTATION OF 2HELPS2B SEIZURE RISK SCORE: A HIGH-VALUE APPROACH TO SEIZURE DETECTION IN THE ICU

Introduction: The use of continuous electroencephalograms (cEEG) has increased over the last decade with guidelines recommending at least 24 hours of monitoring to detect nonconvulsive seizures (NCS). However, recent studies suggest it may be unnecessary to monitor low-risk patients beyond a few hours. Since cEEGs are resource-intensive, we sought to optimize utilization by reducing nonvalue-added time on cEEG, applying a seizure risk score, 2HELPS2B, based on initial EEG findings and patient clinical factors. Methods: We included patients aged >18-years, who required ICU level care and underwent cEEG at a tertiary center between June 2020 and June 2022 (n=252). We excluded patients undergoing cEEG post-cardiac arrest or for ICP or status epilepticus management. Pre-intervention, seizure incidence, cEEG monitoring duration, and 2HELPS2B score were documented via chart review, including EEG reports. For the intervention, we convened a multidisciplinary group of neurointensivists, epileptologists, nurses, and technologists to educate clinical teams on use of the 2HELPS2B seizure risk score. We also implemented a daily touchpoint between the primary team and the reading epileptologist to communicate the seizure risk score and aid in decision-making. Post-intervention data evaluated the impact of utilizing 2HELPS2B on cEEG duration and seizure incidence. Results: Of 252 patients, most had a low risk of seizures with a 2HELPS2B score of 0 (n= 149, 59%), followed by moderate-risk (score: 1; n=79, 31%) and high-risk (score: >2; n=24, 9.5%). Prior to the intervention, monitoring duration for low-, moderate-, and high-risk groups was similar (33 hours vs 32 hours vs 38 hours) and seizure incidence was low except for the high-risk group (0% vs 6.7% vs 50%). Following 2HELPS2B implementation, monitoring duration for all groups decreased with significant reduction in the low-risk group (33 vs 22 hours; p= 0.009), whereas seizure detection rates did not change significantly for any risk group (0% vs 5% vs 50%). Conclusions: Most patients had low or moderate seizure risk based on the 2HELPS2B score, which correlated with a low incidence of recorded seizures on cEEG. Implementing the risk score identified low-risk patients and reduced cEEG monitoring duration without compromising seizure detection rates.

Pediatric Interfacility Transport Modality and Outcomes

<h3>Background</h3> As pediatric facilities continue to coalesce and regionalize, regular access to pediatric specialty care becomes more difficult. This necessitates pediatric interfacility transport (pIFT) which can vary in modality between regular ground transport, CCT ground, rotor and fixed-wing. The literature is sparse regarding these pIFTs, how modality varies and their associated outcomes. <h3>Objective</h3> To examine the relationship between transport modality and outcomes for pediatric interfacility transports. <h3>Methods</h3> This was a retrospective cohort study. Regional transport records were matched with the National EMS Information System (NEMSIS) to identify pediatric (<18yo) interfacility transports to a regional quaternary children's hospital between Feb 2019-Feb 2020. The local EMR was then queried for clinical characteristics as well as outcomes data. Outcome measures included 72-hour mortality, 30-day mortality, length of stay and indicators of escalation of care (EoC). Statistics including regression analyses were performed in R. <h3>Results</h3> Outcomes data was collected for 540 of the 6181 total interfacility transports during the study period. Patient demographics showed 57% male, average age of 4.3 years and the majority were white race. 195 (36%) were ground, 207 (38%) were CCT ground, 75 (14%) were rotor-wing and the remaining 63 (12%) as fixed-wing. Segregating by modality, the shortest was ground transport with an average total duration of 107 minutes (range 36-330) compared to fixed-wing (396 mins, range 144-1991). 52% of all transports went to the ED. A general increase in initial patient acuity was seen as the transport modality escalated: ground transport (1% considered "critical"), CCT ground (74%), fixed-wing (68%) and rotor-wing (88%). Rotor-wing was also associated with the greatest number of age-adjusted abnormal vital signs upon arrival and therefore the aggregated risk score. There were 7 deaths in the first 72 hours and 12 deaths noted in the 30 days since admission. All deaths occurred in patients utilizing critical care transport. Median LOS was 72 hours across all modalities except ground (39 hours). 85% of rotor-wing transports required ICU level care in the first 72 hours as compared to 16% with ground transports. Aggregate EoC scores were worse with rotor-wing IFTs. Multivariate logistic regression did not show association between transport modality and mortality. Modality was only weakly associated with LOS and the aggregate EoC score (p <0.01, aR2 = 0.13). Variables that did show statistical association with outcomes measures included time at beside prior to transport, total risk score, trauma, initial acuity and initial hospital service (p<0.05). <h3>Conclusion</h3> While there were differences in patient demographics, clinical acuity and transport metrics across various forms of pITF, transport modality alone did not explain differences in 72-hour or 30-day mortality. There was only weak statistical association with hospital LOS and EoC. Future work remains to explore the complexities of pediatric interfacility transport and outcomes.

Comorbidities increase COVID-19 hospitalization in young people with type 1 diabetes.

ObjectivesWe evaluated COVID‐19 outcomes in children and young adults with type 1 diabetes (T1D) to determine if those with comorbidities are more likely to experience severe COVID‐19 compared to those without.Research Design and MethodsThis cross‐sectional study included questionnaire data on patients <25 years of age with established T1D and laboratory‐confirmed COVID‐19 from 52 sites across the US between April 2020 and October 2021. We examined patient factors and COVID‐19 outcomes between those with and without comorbidities. Multivariate logistic regression analysis examined the odds of hospitalization among groups, adjusting for age, HbA1c, race and ethnicity, insurance type and duration of diabetes.ResultsSix hundred fifty‐one individuals with T1D and COVID‐19 were analyzed with mean age 15.8 (SD 4.1) years. At least one comorbidity was present in 31%, and more than one in 10%. Obesity and asthma were the most frequently reported comorbidities, present in 19% and 17%, respectively. Hospitalization occurred in 17% of patients and 52% of hospitalized patients required ICU level care. Patients with at least one comorbidity were almost twice as likely to be hospitalized with COVID‐19 than patients with no comorbidities (Odds ratio 2.0, 95% CI: 1.3–3.1). This relationship persisted after adjusting for age, HbA1c, race and ethnicity (minority vs nonminority), insurance type (public vs. private), and duration of diabetes.ConclusionsOur findings show that comorbidities increase the risk for hospitalization with COVID‐19 in children and young adults highlighting the need for tailored COVID‐19 prevention and treatment strategies in T1D.

Point-of-Care Lung Ultrasound Predicts Severe Disease and Death Due to COVID-19: A Prospective Cohort Study.

OBJECTIVES:The clinical utility of point-of-care lung ultrasound (LUS) among hospitalized patients with COVID-19 is unclear.DESIGN:Prospective cohort study.SETTING:A large tertiary care center in Maryland, between April 2020 and September 2021.PATIENTS:Hospitalized adults (≥ 18 yr old) with positive severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction results.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:All patients were scanned using a standardized protocol including 12 lung zones and followed to determine clinical outcomes until hospital discharge and vital status at 28 days. Ultrasounds were independently reviewed for lung and pleural line artifacts and abnormalities, and the mean LUS Score (mLUSS) (ranging from 0 to 3) across lung zones was determined. The primary outcome was time to ICU-level care, defined as high-flow oxygen, noninvasive, or invasive mechanical ventilation, within 28 days of the initial ultrasound. Cox proportional hazards regression models adjusted for age and sex were fit for mLUSS and each ultrasound covariate. A total of 264 participants were enrolled in the study; the median age was 61 years and 114 participants (43.2%) were female. The median mLUSS was 1.0 (interquartile range, 0.5–1.3). Following enrollment, 27 participants (10.0%) went on to require ICU-level care, and 14 (5.3%) subsequently died by 28 days. Each increase in mLUSS at enrollment was associated with disease progression to ICU-level care (adjusted hazard ratio [aHR], 3.61; 95% CI, 1.27–10.2) and 28-day mortality (aHR, 3.10; 95% CI, 1.29–7.50). Pleural line abnormalities were independently associated with disease progression to death (aHR, 20.93; CI, 3.33–131.30).CONCLUSIONS:Participants with a mLUSS greater than or equal to 1 or pleural line changes on LUS had an increased likelihood of subsequent requirement of high-flow oxygen or greater. LUS is a promising tool for assessing risk of COVID-19 progression at the bedside.

Reducing Alarm Fatigue in Maternal Monitoring on Labor and Delivery: A Commentary on Deimplementation in Obstetrics.

Hospital labor and delivery floors frequently operate like intensive care units (ICUs)-with continuous data feeds pouring into central monitoring stations against a background of blaring alarms. Yet the majority of obstetric patients are healthy and do not require ICU-level care. Despite limited organizational recommendations guiding the frequency of vital sign measurement, continuous pulse oximetry is used widely for laboring patients. There is also no evidence that morbidity prevention is linked to specific frequencies of vital sign monitoring in low-risk patients. In fact, studies examining the performance of maternal early warnings systems based on vital signs suggest that these may not reliably provide actionable information regarding maternal physiologic status. Furthermore, it is very possible that intrapartum maternal overmonitoring can impact care negatively by generating alarm fatigue, causing providers to miss actual abnormal vital signs that may precede morbidity. KEY POINTS: · Labor and delivery units may engage in maternal physiologic overmonitoring.. · Overmonitoring increases risk for alarm fatigue.. · Deimplementing low-value care may improve obstetric outcomes..

The displacement of the SARS-CoV-2 variant Delta with Omicron: An investigation of hospital admissions and upper respiratory viral loads.

SummaryBackgroundThe increase in SARS-CoV-2 infections in December 2021 was driven primarily by the Omicron variant, which largely displaced the Delta over a three-week span. Outcomes from infection with Omicron remain uncertain. We evaluated whether clinical outcomes and viral loads differed between Delta and Omicron infections during the period when both variants were co-circulating.MethodsIn this retrospective observational cohort study, remnant clinical specimens, positive for SARS-CoV-2 after standard of care testing at the Johns Hopkins Microbiology Laboratory, between the last week of November and the end of December 2021, were used for whole viral genome sequencing. Cycle threshold values (Ct) for viral RNA, the presence of infectious virus, and levels of respiratory IgG were measured, and clinical outcomes were obtained. Differences in each measure were compared between variants stratified by vaccination status.FindingsThe Omicron variant displaced Delta during the study period and constituted 95% of the circulating lineages by the end of December 2021. Patients with Omicron infections (N = 1,119) were more likely to be vaccinated compared to patients with Delta (N = 908), but were less likely to be admitted (0.33 CI 0.21–0.52), require ICU level care (0.38 CI 0.17–0.87), or succumb to infection (0.26 CI 0.06–1.02) regardless of vaccination status. There was no statistically significant difference in Ct values based on the lineage regardless of the vaccination status. Recovery of infectious virus in cell culture was reduced in boosted patients compared to fully vaccinated without a booster and unvaccinated when infected with the Delta lineage. However, in patients with Omicron infections, recovery of infectious virus was not affected by vaccination.InterpretationCompared to Delta, Omicron was more likely to cause breakthrough infections of vaccinated individuals, yet admissions were less frequent. Admitted patients might develop severe disease comparable to Delta. Efforts for reducing Omicron transmission are required as, though the admission risk might be lower, the increased numbers of infections cause large numbers of hospitalizations.FundingNIH/NIAID Center of Excellence in Influenza Research and Surveillance contract HHS N2772201400007C, Johns Hopkins University, Maryland department of health, Centers for Disease Control and Prevention contract 75D30121C11061, and The Modeling Infectious Diseases in Healthcare Network (MInD) under awards U01CK000589.

61 A Burn Center’s Experience with COVID-19 Positive Burn Patients

IntroductionThe emergence of SARS-COV-2 and the COVID-19 pandemic has complicated the presentation, treatment, and prognosis of all types of patients. Further characterization and analysis of how concomitant COVID-19 infection impacts different patient populations is important for improving treatment strategies. Patients with burn injures often require ICU-level care, mechanical ventilation, and extensive surgical intervention. Concomitant COVID-19 infection in this population presents a new challenge to clinical teams. The purpose of this project is to compare COVID-19 positive burn patients treated at a regional burn center with those that are not.MethodsFollowing IRB approval, our institution’s burn registry was queried from March 2020-June 2021. Data on demographics, injury circumstances, COVID-19 status, and outcomes were collected. Continuous variables were nonparametric and\\compared using Mann-Whitney U test. Categorical variables were compared using Chi-squared with Fischer’s Exact test, where appropriate.ResultsOf the 622 patients admitted at our institution, 19 tested positive for COVID-19 during their hospitalization. Demographic and injury information is reported in Table 1. There were statistically significant differences between the COVID-19 positive and negative groups in regard to race and presence of inhalation injury (p=0.0002, p=0.0002). The TBSA burned was slightly higher in the COVID-19 positive group (9.1 vs 6.7%). COVID-19 positive patients spent more time ventilated (48±32.5 vs.12.2 ± 16.2 days, p=0.0035**) and had both longer ICU (42.71±37.41 vs 11.1±15.4 days, p=0.0175*) and hospital (26.32±32.14 vs 8.177±11.95 days, p< 0.0001***) lengths of stay (LOS). No COVID-19 positive patients died while 5% of the COVID-19 negative patients did. All outcomes were statistically significant.ConclusionsDespite similar TBSA injury burden and age breakdown, patients at our institution who tested positive for COVID-19 required more time on the ventilator and were hospitalized longer. People of color had a higher percentage of positive tests than their Caucasian counterparts. While mortality rates were higher in the COVID-19 negative cohort, morbidities associated with longer LOS must be considered.

1215. A Mixed Methods Study on Severe Bacterial Infections in People Who Inject Drugs

BackgroundSevere bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This mixed methods study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use.MethodsWe conducted 34 quantitative and 15 qualitative interviews between August 2020 and June 2021 at Bellevue Hospital in New York City. Eligible participants were (1) >/= 18 year of age, (2) admitted with a SBI, and (3) reported injection drug use within the 90 days prior to admission. Quantitative and qualitative data was obtained using a quantitative survey and in-depth, semi structured interviews of participants respectively. Analysis was performed to examine trends and explore common themes potentially contributing factors to SBI.ResultsOf the 34 participants included, the median age was 37.5, 85% were male, 53% white, and 65% reported being homeless within the past 3 months. Endocarditis was the most common primary diagnosis (65%). Median length of hospital stay was 24 days and 35% required ICU level care during admission. A causative microorganism was identified in 85% of participants and 50% had Staphylococcus aureus as the sole organism. Discharges against medical advice occurred in 35%. Daily injection drug use in prior 30 days was 95% with a median of 10 injections per day. In the 30 days prior to admission, 50% reported an increase in injection frequency, 80% reported reusing needles and/or syringes, 75% reused cookers, 65% reused cottons. Analysis of qualitative interview data revealed high risk injection behaviors. Participants were not practicing and unaware of strategies to reduce their risk of drug injection-related SBI. Prior hospitalizations for SBI did not impact on this knowledge deficit on what constitutes bacterial infection risk and how to prevent it. ConclusionStudy findings highlight the complexity of the injection drug use process and the potential social and physiological pathways leading to SBI. Multiple domains at the structural, network, and individual level that impact drug injection practices and provide context by which these factors predispose and lead to physiological tissue damage and the development of SBI among PWID. Disclosures Benjamin Eckhardt, MD, MS, Gilead Sciences (Grant/Research Support)

989. Isavuconazonium Sulfate Treatment of Blastomycosis: A Case Series

Abstract Background Blastomyces fungi, endemic to the Ohio and Mississippi River Valleys, cause pneumonia and disseminated disease in both immunocompetent and immunocompromised patients. Prolonged antifungal therapy is commonly complicated by hepatic toxicity, QT prolongation, and drug interactions. Isavuconazonium sulfate is dosed once daily, does not prolong the QT interval, and has fewer drug interactions, but there is a paucity of data for its use in blastomycosis. Methods This case series of blastomycosis treated with isavuconazonium sulfate at the University of Wisconsin Hospital and Clinics from 2015 to December 2019 focuses on long term outcomes. Inclusion criteria were adults, that received at least one day of isavuconazole. Exclusion criteria was no blastomycosis diagnosis. Results Of 14 cases, median age was 53 years, 6/14 were female, 11/14 White, 2/14 Black, 1/14 Hmong, 6/14 had a solid organ transplant (4 renal, 1 heart, 1 bilateral lung), 1/14 on a TNF-alpha inhibitor (infliximab). Most cases, 9/14 had moderate severity illness requiring inpatient care, 2/14 required ICU level care, and 3/14 were outpatient. Most cases, 11/14, were initially treated with Liposomal Amphotericin B (LAMB) for a median duration of 14 days, 9/14 cases received itraconazole, 8/14 voriconazole, 1/14 posaconazole. Isavuconazonium sulfate was started after adverse drug effects with other azoles in 10/14 cases, prolonged QT interval in 3/14, drug interactions in 2/14, subtherapeutic azole levels in 2/14. Isavuconazonium sulfate was well tolerated and used for median duration of 255 (average 68% total treatment course). 3/14 cases had adverse reactions to isavuconazonium sulfate: nausea, rash, elevated liver enzymes. There was only one death during therapy from a fatal hemorrhagic stroke, and 2/14 cases were still on therapy at end of data collection. 11/14 were cured after treatment course. Conclusion This is the largest case series treating Blastomycosis with isavuconazonium sulfate, and it adds to the evidence that isavuconazonium sulfate can be safely used to treat pulmonary and disseminated blastomycosis. Prospective data is needed to compare isavuconazonium sulfate to other antifungals for the treatment of Blastomycosis. Disclosures All Authors: No reported disclosures

310. Cryptococcal Infection Following COVID-19 infection in Solid Organ Transplant Recipients: A Case Series

BackgroundFungal infections have been identified with or following SARS-CoV-2 infection, most commonly COVID associated pulmonary aspergillosis. Cryptococcus species are ubiquitous in the environment and the third most common invasive fungal infection following Solid Organ Transplant (SOT). We describe four cases of concurrent or subsequent cryptococcal infection within 90 days following COVID-19 infection.MethodsWe conducted a retrospective study of patients presenting with proven cryptococcosis either concurrently or within 90 days following COVID-19 diagnosis. Cases were identified March 2020 through May 2021. All were seen at the University of Alabama in Birmingham, a regional referral and comprehensive transplant center. Exemption for this review was approved by our IRB.ResultsFour cases were identified, all were SOT recipients. Case details are provided in Table 1. No patients required ICU level care at any point. COVID-19 treatment included 10 days of increased steroids for 3 patients, remdesivir for 2, and 1 received no treatment for COVID-19. In contrast to the typical time-course for cryptococcal infection post-SOT (median time approx. 500 days post-transplant), three patients were greater than 2 years post-transplant and were without rejection or recent changes in immunosuppression. Patient 1 was less than 6 months post liver-kidney transplant and was diagnosed at time of admission with concurrent COVID-19 and cryptococcal pneumonia. Infection was disseminated in the other 3 cases including positive blood cultures in 2 patients and cryptococcal meningitis (CM) in 2 patients. CM cases presented later following COVID-19 and had the longest delay between symptom onset (headache, neurologic symptoms) and CM diagnosis. One patient had CM 8 years prior, but had done extremely well off fluconazole for over 6 years prior to this recurrence. All patients are doing well at most recent follow-up evaluations.Table 1. Summary of Cases ConclusionWe describe the first case series with a temporal association between SARS-CoV-2 infection and cryptococcosis. All cases were immunocompromised due to SOT. Some symptoms were attributed to post-COVID syndrome leading to significant delays in diagnosis for those patietns, highlighting the importance of considering this association for at-risk patients.Disclosures Todd P. McCarty, MD, Cidara (Grant/Research Support)GenMark (Grant/Research Support, Other Financial or Material Support, Honoraria for Research Presentation)T2 Biosystems (Consultant)

COVID-19 in Patients With Hematologic Malignancies: A Single Center Retrospective Study.

Initial studies that described the novel coronavirus (COVID-19) reported increased morbidity and mortality in patients with cancer. Of this group, patients with hematologic malignancies (HM) had the highest disease severity and death rates. Subsequent studies have attempted to better describe how COVID-19 affects patients with HM. However, these studies have yielded variable and often contradictory results. We present our single-institution experience with patients with HM who were diagnosed with COVID-19 from March 2020 to March 2021. We report 62 total cases with 10 patients who died during this time. The overall mortality was 16.1%. Mortality during the first two waves of COVID was 27.8% and 25%. Mortality during the third wave of COVID was 10%. The median age of patients was 67 years (range 20-89 years). 55% of patients had lymphoid malignancies and the majority had active disease at the time of diagnosis with COVID-19. 87% of patients had more than one co-morbidity. Important co-morbidities included cardiovascular disease and smoking history. 38.7% of patients had asymptomatic or mild disease, 54.8% required hospitalization, and 17.5% required ICU level care. In patients who required ICU level care, the mortality was 60%.

Management of Minor Traumatic Brain Injury in an ED Observation Unit.

IntroductionTraumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.MethodsThis study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.ResultsThere were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.ConclusionPatients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Cancer, transplant, and immunocompromising conditions were not significantly associated with severe illness or death in hospitalized COVID-19 patients.

ObjectivePatients with cancer, transplant, and other immunocompromising conditions are at uncertain risk of severe COVID-19 illness. This study aimed to clarify whether patients with immunocompromising conditions were more likely to develop severe COVID-19 illness in a single urban academic medical center.MethodsA retrospective chart review and electronic data extraction of the first 401 patients at the University of Chicago Hospitals with SARS-CoV-2 infection was performed. Patients met criteria for severe COVID-19 illness if they required ICU level care, high flow oxygen, positive pressure support, helmet non-invasive ventilation, mechanical ventilation, or ECMO, developed ARDS, or died.ResultsThe mean age was 60 years, 52% were women, 90% were African American, and mortality at 30 days post discharge was 13%. Severe COVID-19 illness was found in 168 (40%) patients. Of the 56 patients with past or current cancer, 25 (45%) had severe illness (p=0.76). Of the 55 patients with other immunocompromised conditions, 24 (44%) had severe illness (p=0.89) After controlling for age, sex, and race, neither cancer (p=0.73) nor immunocompromised conditions (p=0.64) were associated with severe illness.ConclusionNo association was found between severe COVID-19 illness and cancer, transplant, and other immunocompromising conditions in a cohort of mostly African American patients.

Hospital Admissions from the Emergency Department and Subsequent Critical Care Interventions for Influenza during Pregnancy.

The objectives of this study were to determine (1) whether obstetrical patients were more likely to be admitted from the emergency department (ED) for influenza compared with nonpregnant women, and (2) require critical care interventions once admitted. Using data from the 2006 to 2011 Nationwide Emergency Department Sample, ED encounters for influenza for women aged 15 to 54 years without underlying chronic medical conditions were identified. Women were categorized as pregnant or nonpregnant using billing codes. Multivariable log linear models were fit to evaluate the relative risk of admission from the ED and the risk of intensive care unit (ICU)-level interventions including mechanical ventilation and central monitoring with pregnancy status as the exposure of interest. Measures of association were described with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs). We identified 15.9 million ED encounters for influenza of which 4% occurred among pregnant women. Pregnant patients with influenza were nearly three times as likely to be admitted as nonpregnant patients (aRR = 2.99, 95% CI: 2.94, 3.05). Once admitted, obstetric patients were at 72% higher risk of ICU-level interventions (aRR = 1.72, 95% CI: 1.61, 1.84). Of pregnant women admitted from the ED, 9.3% required ICU-level interventions such as mechanical ventilation or central monitoring. Older patients and those with Medicare were also at high risk of admission and ICU-level interventions (p < 0.01). Pregnancy confers three times the risk of admission from the ED for influenza and pregnant women are significantly more likely to require ICU-level medical interventions compared with women of similar age. These findings confirm the significant disease burden from influenza in the obstetric population and the public health importance of reducing infection risk. · Pregnancy confers three times the risk of admission from the ED for influenza.. · Pregnant women admitted with influenza are significantly more likely to require ICU-level care.. · Influenza represents a significant disease burden in the obstetric population.

Artificial intelligence-based prediction of transfusion in the intensive care unit in patients with gastrointestinal bleeding

ObjectiveGastrointestinal (GI) bleeding commonly requires intensive care unit (ICU) in cases of potentialhaemodynamiccompromise or likely urgent intervention. However, manypatientsadmitted to the ICU stop bleeding and do not require further intervention,...

Geriatric Intensive Care Unit Admission Protocol

Background and Hypothesis: &#x0D; The Society of Critical Care Medicine has recommended protocolized admission and discharge criteria for the ICU, but there is little supporting evidence for these guidelines. Our goal is to find predictors supported by data that can consistently triage patients appropriately on admission and decrease the need to upgrade the level of care during the same hospital stay. We hypothesized that applying a protocol would reduce the number of unplanned ICU admissions in our institution. &#x0D; &#x0D; Methods: &#x0D; We retrospectively applied our protocol to patients sixty-five years or older from the trauma registry at Methodist Hospital admitted between January 1 and December 31, 2019. Patients who did not have an unplanned ICU admission during hospital stay were used as the control group, while those who had an unplanned ICU admission event were considered the experimental group. After this, we used crosstabulation and Fisher’s exact test to analyze the data. &#x0D; &#x0D; Results: &#x0D; We reviewed one thousand one hundred forty-six (1146) subjects with 1088 in the control group and 58 in the experimental group. Subjects in the experimental group were statistically more likely to have COPD (OR: 2.646, p=0.001), been transfused &gt; two units of PRBC in the first 24 hours (OR: 5.303, p=0.000), or to have greater than two rib fractures (OR: 2.469, p=0.002). &#x0D; &#x0D; Conclusion and Potential Impact: &#x0D; This study demonstrates that applying this protocol can capture elderly patients who will likely require ICU level care during their hospitalization. COPD, &gt; two rib fractures, and transfusion of &gt; two units PRBC during the first 24 hours appear to be significant predictors of clinical deterioration. Unplanned ICU admissions are associated with increased hospital and ICU length of stay. We must develop evidence-based protocols to decrease morbidity and cost associated with unplanned ICU admissions.