Intensive Care Resources Research Articles

Policy Proposals for Mitigating Intensive Care Unit Strain: Insights from the COVID-19 Pandemic.

Intensive care unit (ICU) strain, characterized by a discrepancy between perceived or actual intensive care resources and demand, significantly impacts patient outcomes and healthcare worker well-being. The coronavirus disease (COVID-19) pandemic exacerbated ICU strain, leading to increased mortality and extended hospital stays, affecting both critically ill patients with and without COVID-19. A systematic review identified 16 leading and lagging indicators of ICU capacity strain, including queuing, premature and after-hours ICU discharge, use of temporary space, length of stay, burnout, staffing and nurse-to-patient ratio, ICU census, acuity and turnover, standardized mortality ratio, readmissions, availability of critical supplies, ventilator use, and surgery cancellation. However, variability in operational definitions and limited evidence regarding the reliability, validity, usability, and feasibility limit the value of single indicators for informed strategic planning and policy guidance. Regional and national policies and programs are essential to enhance real-time monitoring for effective management of critical care resources, and they mitigate the impact of ICU strain, facilitating complex interhospital transfers to reduce strain and ensuring comprehensive strategies for enhancing ICU resilience. Proactive regional cooperation is advocated for policy formulation, knowledge exchange, and resource allocation to anticipate and mitigate ICU strain, ensuring equitable healthcare access during global health crises. The policy implications for future preparedness emphasize the importance of evidence-based triage and adaptable patient management strategies alongside ethical considerations in resource allocation and the role of behavioral economic insights in optimizing resource utilization and collaborative healthcare practices. This multifaceted approach for addressing ICU strain comprehensively and effectively during a pandemic would promote health equity and enhance healthcare system resilience under both routine operations and crisis conditions.

A cross-country comparison of the organisation and reimbursement of intensive care in Europe

Abstract Background During the pandemic, intensive care capacity was a heavily discussed topic in Europe. Many European countries have increased their intensive care capacities to ensure treatment of all COVID-19 patients. A study, however, revealed that organisational characteristics, among other factors, were associated with in-hospital mortality. Our study thus aimed at reviewing international models for the organisation and reimbursement of intensive care. Methods Based on a scoping review, a number of European countries (Denmark, England, France, Germany, Italy, the Netherlands, Sweden) was selected for a questionnaire-based expert survey. Results In most countries, intensive care is defined by law, while the definition in two countries has a recommendatory character and/or is driven by reimbursement. In line with the European Society of Intensive Care Medicine’s recommendations, the majority of countries has organised intensive care around 2-3 different (heterogeneously defined) levels of care for which reimbursement sometimes differs according to the level. For most countries, the number of physical (i.e., number of operable beds) as well as human resources (i.e., nurses) in intensive care is unknown. Many countries have an intensive care register which, in the case of Germany, was only implemented as a response to the pandemic. However, comparability is limited due to differences in indicators used. Although promising telemedical approaches in intensive care do exist, their use is not yet formalized in most countries. Conclusions Most countries rely on a level-based organisation of intensive care, even though clear evidence on their effect is missing. Heterogeneity of definitions as well as quality monitoring makes a comparison difficult. Further research is needed to better understand best practices and thus increase resilience as well as pandemic preparedness. Telemedical interventions could elevate (access to) high-quality care, especially in times of crises. Key messages • Further research is needed to better understand best practices and thus increase resilience as well as pandemic preparedness. • Telemedicine could elevate (access to) high-quality intensive care, especially in times of crises.

Making health information understandable: the COVID-19 patient guideline

Abstract Issue Evidence-based practice guidelines offer a reliable source of information, providing recommendations based on the most recent evidence. However, these guidelines are complex and difficult to understand for laypersons. This creates a knowledge gap, affecting shared-decision making, treatment acceptance, understanding of a disease and recommendations of disease prevention. Description of the problem Patient guidelines (PatG) aim to bridge this knowledge-gap by providing simplified versions of practice guidelines in lay language. This is a common practice internationally. An example is the German evidence-based COVID-19 practice guideline, published in 01/2024. In March, a multidisciplinary team, including a patient representative, created and reviewed a PatG outline, prioritising topics based on patient relevance, and discussed relevant information. The authors translated guideline recommendations into lay language, researched additional information, and created supporting graphics. A methodology chapter explaining both guidelines and a short medical term dictionary were also included. Results In 05/2024, the COVID-19 PatG, around 70 pages long, was finalized including information on treatment, diagnostics, intensive care, and support resources. A feedback round was initiated. Comments will be incorporated for the final version to be published in the national guideline registry by end of 05/2024. Updates of the PatG and practice guidelines will occur frequently. Lessons We faced challenges in simplifying medical concepts and interventions and accurately translating recommendations without losing key information. The length of the PatG may discourage readers. Despite these challenges, we are committed to enhancing accessibility, using simpler language, and adding supporting graphics to improve the PatG in the future. Key messages • Despite some challenges, patient guidelines pose as a reliable form of patient information. • The COVID-19 patient guideline is a reliable and evidence-based source of information.

Critical care resources in surge response: towards real-time situation awareness

ABSTRACT In large-scale emergencies and disasters, real-time situation awareness around health resources can be lifesaving. Understanding the situation at hand, the pressing needs and the actions needed often using information systems that require manual data entry. Relying on humans to enter data manually during surge response is both error-prone and an impediment to the critical requirement of real-time situation awareness. This paper explores the potential of Ultra-High Frequency Radio Frequency Identification (UHF RFID) technology to automate the process of manual data entry followed in providing situation awareness related to critical care resources during surge response. Using design science, an RFID-based prototype was developed to identify and track intensive care resources in real-time. The system was tested in a simulated hospital ward environment to understand deployment challenges and a dashboard was developed to reflect real-time data from multiple sources simultaneously. When properly deployed, UHF RFID can be a viable approach to automating critical care reporting during surge response. Automating routine processes can enhance data quality and minimise workload on health professionals leading to better patient care and evidence based decision-making.

Joint [Formula: see text] and Image Reconstruction in Low-Field MRI by Physics-Informed Deep-Learning.

We present a model-based image reconstruction approach based on unrolled neural networks which corrects for image distortion and noise in low-field ( B0 ∼ 50 mT) MRI. Utilising knowledge about the underlying physics, a novel network architecture (SH-Net) is introduced which involves the estimation of spherical harmonic coefficients to guarantee a spatially smooth field map estimate. The SH-Net is integrated in an end-to-end trainable model which jointly estimates the B0-field map as well as the image. Experiments were conducted on retrospectively simulated low-field data of human knees. We compare our model to different model-based approaches at distinct noise levels and various B0-field distributions. Our results show that our physics-informed neural network approach outperforms the purely model-based methods by improving the PSNR up to 11.7% and the RMSE up to 86.3%. Our end-to-end trained model-based approach outperforms existing methods in reconstructing image and B0-field maps in the low-field regime. low-field MRI is becoming increasingly more popular as it enables access to MR in challenging situations such as intensive care units or resource poor areas. Our method allows for fast and accurate image reconstruction in such low-field imaging with B0-inhomogeneity compensation under a wide range of various environmental conditions.

Intensive care unit caseload and workload and their association with outcomes in critically unwell patients: a large registry-based cohort analysis

BackgroundToo high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU).MethodsRetrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients’ respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period.Results415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99–1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02–1.16), p = 0.008 for ≤ 50% and 1.10 (1.05–1.15), p < 0.0001 for 51–75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06–1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21–30, lower [0.88 (0.78–0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01–1.19), p = 0.035 for 31–40, 1.28 (1.02–1.60), p = 0.033 for > 40].ConclusionsIn a system with comparably high intensive care resources and mandatory staffing levels, patients’ survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.

On the Morality of Reallocating Life-Sustaining Interventions in Times of Scarcity

Abstract As coronavirus disease 2019 made its way across the world in 2019, health systems began to develop guidelines to allocate what was expected to be a scarcity of medical resources. Considerable attention was given to triaging intensive care resources such as ventilators. While there was general agreement among bioethicists and policymakers that it may be permissible to withhold life-sustaining interventions from patients with poor prognoses in order to make them available to patients with better prognoses, there was disagreement about the permissibility of withdrawing such interventions for this purpose. Some maintained that the doctrine of double effect (DDE) revealed the intrinsic wrongness of such acts of reallocation. This article argues that so long as there is transparency and effective ongoing communication, the DDE may permit the discontinuation of life-sustaining interventions from patients who may still benefit from them in order to make them available to patients with more favorable prognoses.

Clinical Outcomes of Early vs. Late Tracheostomy in Ventilated COVID-19 Patients.

Background The coronavirus disease 2019 (COVID-19) global pandemic prompted a significant use of intensive care resources for managing hypoxic respiratory failure. A substantial portion of these patients required mechanical ventilation. While intubation is common, its impact on mortality improvement has been questionable. Tracheostomies have become crucial for patients needing prolonged ventilation. However, tracheostomies also risk infections, ranging from early-stage mild cellulitis to later-stage nosocomial pneumonia. Our study evaluates the incidence of bacterial infections in COVID-19 patients who underwent tracheostomy early (within 14 days) versus late (more than 14 days after initiation of mechanical ventilation) during their stay in the intensive care unit (ICU). Methods We conducted a retrospective single-center study at Royal Medical Services Military Hospital. The study included COVID-19 patients who underwent tracheostomy and were admitted to the ICU from March 2020 to March 2022. We analyzed the incidence of ventilator-associated pneumonia, the timing of weaning from mechanical ventilation, and outcomes between early and late tracheostomized patients. Analyzed variables included demographics, comorbidities, use of steroids, tocilizumab, inflammation parameters, tracheostomy timing, incidence of bacterial infections, complications, and outcomes. Results The study comprised 36 patients. We found no statistically significant difference in the incidence of bacterial infections between the early and late tracheostomy groups (P>0.05). Complications and overall outcomes did not show significant statistical associations. Inotropes use was more frequent in the late tracheostomy group (P=0.122). In contrast, continuous renal replacement therapy was higher in the early tracheostomy group, showing no significant association (P>0.05). Mortality was higher in the early tracheostomy group, with nine deaths compared to seven in the late tracheostomy group. Interestingly, infection with Acinetobacter baumannii was associated with a statistically significant lower mortality rate, with 75% survival following tracheostomy. Conclusions Findings suggest that tracheostomy timing does not significantly impact the incidence of bacterial pneumonia or other complications, such as the use of inotropes, continuous renal replacement therapy, or mortality rates. These results support the use of personalized decision-making while conducting tracheostomies. Further research is necessary to determine the impacts of tracheostomy timing on patient outcomes more definitively.

Explainable Boosting Machine approach identifies risk factors for acute renal failure

BackgroundRisk stratification and outcome prediction are crucial for intensive care resource planning. In addressing the large data sets of intensive care unit (ICU) patients, we employed the Explainable Boosting Machine (EBM), a novel machine learning model, to identify determinants of acute kidney injury (AKI) in these patients. AKI significantly impacts outcomes in the critically ill.MethodsAn analysis of 3572 ICU patients was conducted. Variables such as average central venous pressure (CVP), mean arterial pressure (MAP), age, gender, and comorbidities were examined. This analysis combined traditional statistical methods with the EBM to gain a detailed understanding of AKI risk factors.ResultsOur analysis revealed chronic kidney disease, heart failure, arrhythmias, liver disease, and anemia as significant comorbidities influencing AKI risk, with liver disease and anemia being particularly impactful. Surgical factors were also key; lower GI surgery heightened AKI risk, while neurosurgery was associated with a reduced risk. EBM identified four crucial variables affecting AKI prediction: anemia, liver disease, and average CVP increased AKI risk, whereas neurosurgery decreased it. Age was a progressive risk factor, with risk escalating after the age of 50 years. Hemodynamic instability, marked by a MAP below 65 mmHg, was strongly linked to AKI, showcasing a threshold effect at 60 mmHg. Intriguingly, average CVP was a significant predictor, with a critical threshold at 10.7 mmHg.ConclusionUsing an Explainable Boosting Machine enhance the precision in AKI risk factors in ICU patients, providing a more nuanced understanding of known AKI risks. This approach allows for refined predictive modeling of AKI, effectively overcoming the limitations of traditional statistical models.

Ethical prioritization of critical care resources during COVID-19: perspectives from Italy and the United States.

This article examines some of the ethical challenges of prioritizing intensive care resources during the Covid-19 pandemic by comparing the Italian and United States contexts. After presenting an overview to the clinical, ethical, and public debates in Italy, the article will discuss the development of triage allocation protocols in United States hospitals. Resource allocation criteria underwent increased scrutiny and critique in both countries, which resulted in modified professional and expert guidance regarding healthcare ethics during times of emergency and resource scarcity.

독일 연방헌법재판소 ‘Triage’ 결정(2021) 분석을 통해 본 장애인에 대한 차별 금지

During the COVID-19 pandemic, there were concerns that the German healthcare system's triage system for prioritizing care could be in crisis. ‘Triage’ is the process by which healthcare providers decide which patients are prioritized for treatment in situations where critical care medical resources cannot keep up with the demand. There are understandable concerns that people with disabilities, who are at higher risk of becoming critically ill with the COVID-19 virus, could be unfavorably treated by the way these decisions are made. The applicants argued that federal and state measures to prevent this were inadequate and insufficient in the face of the uncertainty of a possible shortage of medical resources. The legislator was therefore obliged to provide a legal basis for triage and to effectively regulate the classification to prevent discrimination. The Federal Constitutional Court found that the classification of patients during the COVID-19 pandemic exposed the applicants to the risk of being disadvantaged on account of their disability in relation to the allocation of intensive care resources. The Court also ordered the legislator to fulfill its duty to act promptly and to take preventive measures to prevent discrimination against persons with disabilities. This decision has been criticized of overlooking the argument that the consideration of the severity of the disease and the course of the disease in the triage process constitutes indirect discrimination against people with disabilities. The Federal Constitutional Court also left open the possibility of indirect discrimination when it did not declare unconstitutional the criteria for determining the likelihood of clinical success, i.e., the likelihood of surviving an acute illness. The ‘triage criterion’ may also violate the European Convention on Human Rights because the European Court of Human Rights has recognized a comprehensive concept of indirect discrimination within the Convention. In this case, the Triage Criteria could put people with disabilities at a disadvantage compared to people without disabilities in that the criteria of disability could still have a negative impact on the course and severity of COVID-19-19 infection, which constitutes indirect discrimination. The Federal Constitutional Court should endeavor to decide important and urgent issues promptly, but not to lose sight of the underlying approach to the problem and the various forms of discrimination that can result from it.

Scarce, scarcer, scarcest: Sensitivity-flexible AI-based planning of elective surgeries for efficient and effective intensive care resource management

Scarce, scarcer, scarcest: Sensitivity-flexible AI-based planning of elective surgeries for efficient and effective intensive care resource management

Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization.

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

Safety and Feasibility of a “Fast‐Track” Monitoring Protocol for Patients Treated With Intravenous Thrombolytic Therapy

Background Our health care systems continue to face significant strain due to chronically taxed intensive care resources. A subgroup of patients following thrombolytic stroke may not require prolonged intensive monitoring, alleviating some burden. Here, we describe the safety, feasibility, and utility of a Fast‐Track Protocol (FTP) for early deescalation of high‐acuity monitoring. Methods We compared a prospective cohort of patients on the FTP at our stroke centers from April 2020 to February 2022 to a similar retrospective cohort. Those who presented with a National Institutes of Health Stroke Scale &lt;10 and without large‐vessel occlusion or flow‐limiting stenosis, intravenous antihypertensive use, and any hemodynamic or respiratory concerns were eligible. Primary outcomes included early neurologic deterioration, defined as worsening of National Institutes of Health Stroke Scale score of ≥4 points at 24 hours, parenchymal hemorrhage, and symptomatic intracranial hemorrhage. Results Of 574 patients undergoing thrombolysis, 119 (21%) were eligible for the FTP. A total of 100 (88%) were included for analysis. The median±interquartile range hospitalization was 2.0±1.6 days. None of the 4 cases of early neurologic deterioration were due to hemorrhage. No symptomatic intracranial hemorrhages occurred, and no patients on the FTP were transferred back to the intensive care unit. Median±interquartile range 90‐day modified Rankin scale score was 1±1. Conclusion FTP is a safe and feasible strategy to triage intensive care unit patients and decrease unnecessary intensive care unit monitoring. This is important in a postpandemic era as intensive care unit resources continue to fluctuate. Future studies are needed to establish the optimal level of monitoring in patients following thrombolysis.

Intelligent method to predict intensive care unit admission after drainage operation in patients with deep neck space abscess: A multicenter retrospective study.

A deep neck space abscess (DNSA) is a critical condition resulting from infection of deep neck fascia and soft issue, leading to high morbidity and mortality. Therefore, intensive care can be very significant for patients with DNSA. This study aimed to develop models to predict the need for postoperative intensive care in patients with DNSA. We retrospectively analyzed the records of 332 patients with DNSA who received drainage operation between 2015 and 2020. Multivariate logistic regression analysis and the eXtrem Gradient Boosting (XGBoost) algorithm were used to develop predictive models. We developed two predictive models, the nomogram and the XGBoost model. The area under the curve (AUC) of the nomogram was 0.911 and of the XGBoost model was 0.935. We developed two predictive models for guiding clinical decision making for postoperative ICU admission for DNSA patients, which may help improve prognosis and optimize intensive care resource allocation.

Mortality Risk Factors in Severe and Critical COVID-19 Patients at Antsiranana University Hospital

Backgrounds: This study focuses on identifying risk factors associated with mortality in patients with severe or critical COVID- 19 at the University Hospital of Antsiranana, Madagascar. Since the pandemic’s onset, African healthcare systems have faced significant challenges due to limited intensive care resources, contributing to higher mortality rates. Madagascar has reported a COVID-19 case fatality rate of around 2%. The aim of this study is to identify mortal- ity risk factors to improve patient management and reduce death rates in severely ill patients. Methods: This retrospective cohort study was conducted from March 2020 to March 2022, including hospitalized patients with confirmed or probable COVID-19 infection. Data on demographics, clinical symptoms, laboratory tests, and treatments were collected. Univariate and multivariate analyses were performed to identify risk factors associated with mortality. Results: Out of 124 patients, 25 (20.2%) died. The median age was 58.6 years, with 48.4% over the age of 60. The most common symptoms were cough (73.4%), dyspnea (70.2%), and fever (68.5%). Comorbidities were present in 65.32% of the patients, with hypertension (50%) and diabetes (29.8%) being the most frequent. Multivariate anal- ysis revealed that cardiac and respiratory deterioration, as well as shock, were strongly associated with increased mortality risk Conclusion: The findings confirm that comorbidities, particularly hypertension and diabetes, are significant risk factors for COVID-19 mortality. Respiratory decline, cardiac decompensation, and altered consciousness at admis- sion were also critical prognostic indicators. Hospital mortality rates were consistent with other studies in similar low-resource settings, though the actual rates may be underreported due to limited healthcare resources. This study highlights the importance of early management of comorbidities and respiratory and cardiac complications in severe COVID-19 patients to reduce mortality.

Comparing Opioid with Opioid-free Anesthesia Technique in Neonates Undergoing Tracheoesophageal Fistula Repair.

Tracheoesophageal fistula (TEF) is a congenital disorder that presents as a surgical emergency in neonates. In regions where neonatal intensive care unit facilities and resources are inadequate and skilled personnel are scarce, not extubating neonates on table, contributes to mortality. Our aim was to assess and compare the on-table extubation rate, extubation time, and postoperative pain scores between opioid and opioid-free anesthesia techniques in neonates undergoing surgical repair of TEF. We conducted a prospective, single-blind, randomized trial over 18 months between January 2021 and June 2022 in Safdarjung Hospital, New Delhi on 60 full-term neonates scheduled for TEF surgeries randomly allocated to two groups according to the mode of analgesia administered. Group O were given fentanyl injection 1 µg/kg intravenous (IV) loading dose with IV injection. acetaminophen at 7.5 mg/kg and top-up of 0.25 µg/kg fentanyl IV si opus sit. Group NO were given pre-surgical local infiltration and intercostal block with 0.25% and 0.5% bupivacaine, respectively, with IV acetaminophen at 7.5 mg/kg. Mean age in days, gender distribution, and weight in both groups were statistically comparable. The difference in the number of neonates extubated on table was statistically significant (p =0.002) in group NO compared to group O. Lower mean extubation time was seen in group NO (9.0 min 40.0 secs±3.0 min 3.0 secs) compared to group O (16.0 min 45.0 secs±8.0 min 5.0 secs) (p < 0.001). There was a statistically significant (p =0.010) lower Neonatal Infant Pain Scale score in group NO with mean and SD as 1.8±0.8 compared with group O, 2.5±1.1 at 90 min. In neonates undergoing TEF repair, opioid-free anesthesia is a safe and effective method, providing a better extubation rate, faster time to extubation, and better postoperative pain control.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury

IntroductionSevere traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. MethodsWe queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. ResultsWe identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). ConclusionsPN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Hospitalization Among Patients Treated With Molnupiravir: A Retrospective Study of Administrative Data

Molnupiravir is an oral antiviral agent authorized for emergency use to treat mild to moderate cases of coronavirus disease 2019 (COVID-19) in adults at high risk for progression to severe clinical outcomes. This study aimed to describe patient characteristics and health outcomes in a cohort of adult patients treated with molnupiravir in an outpatient setting in the United States. This was a retrospective cohort study of adults identified in the HealthVerity database with a pharmacy claim for molnupiravir between December 24, 2021, and April 14, 2022. Hospitalization and health care use were assessed over the 28 days after the molnupiravir pharmacy claim. Among 26,554 patients identified, 71.1% were aged ≥50 years and 58.9% were female. A total of 8794 patients (33.1%) had received at least 1 dose of the COVID-19 vaccine. The most prevalent risk factors for severe COVID-19 identified were hypertension (45.1%), steroid and/or immunosuppressant use (39.6%), and being obese or overweight (24.6%), with 79.1% of patients having ≥1 risk factor. The majority (61.0%) of patients were prescribed comedications contraindicated with or had the potential for major drug-drug interactions with ritonavir-containing regimens. Within 28 days after initiating molnupiravir, 3.3% of patients were hospitalized for any cause and 1.7% for COVID-19-related reasons. Among all hospitalized patients, 9.2% were admitted to an intensive care unit, 3.9% received oxygen, and 3.8% required mechanical ventilation. The majority of patients treated with molnupiravir in early 2022 had at least one risk factor for severe COVID-19 and had comedications that could require treatment modification or monitoring if given a ritonavir-containing regimen. Hospitalization was uncommon after treatment with molnupiravir, with COVID-19-related inpatient admission in <2% of patients. Among those hospitalized, patient use of intensive care and oxygen-based resources was infrequent. The study design, however, does not permit any conclusions regarding the effectiveness of molnupiravir.

Translating theories of justice into a practice model for triage of scarce intensive care resources during a pandemic.

During the COVID-19 pandemic, national triage guidelines were developed to address the anticipated shortage of life-saving resources, should ICU capacities be overloaded. Rationing and triage imply that in addition to individual patient interests, interests of population health have to be integrated. The transfer of theoretical and empirical knowledge into feasible and useful practice models and their implementation in clinical settings need to be improved. This paper analyzes how triage protocols could translate abstract theories of distributive justice into concrete material and procedural criteria for rationing intensive care resources during a pandemic. We reconstruct the development and implementation of a rationing protocol at a German university hospital: describing the ethical challenge of triage, clarifying the aspirational norms, and summarizing specific norms of fair triage and allocation for developing an institutional policy and practice model and implementing it. We reflect on how critical topics are seen by clinicians and what helped manage the perceived burdens of the triage dilemma. We analyze what can be learned from this debate regarding the difficult issues around triage protocols and their potential implementation into clinical settings. Analyzing the ought-to-is gap of triage, integrating abstract ethical principles into practical concepts, and evaluating those should clarify the benefits and risks of different allocation options. We seek to inform debates on triage concepts and policies to ensure the best possible treatment and fair allocation of resources as well as to help protect patients and professionals in worst-case scenarios.