Risk Of Clinical Deterioration Research Articles

Telemedical management in patients waiting for transcatheter aortic valve implantation: the ResKriVer-TAVI study design.

The majority of patients with severe aortic stenosis (AS) planned for transcatheter aortic valve implantation (TAVI) are elective outpatients. During the COVID-19 pandemic, the time between the heart team's decision and TAVI increased due to limited healthcare resources. We therefore implemented telemedical approaches to identify AS patients at risk for clinical deterioration during the waiting time. The purpose of the prospective, randomized, controlled ResKriVer-TAVI study (DRKS00027842) is to investigate whether a digital concept of telemedical interventional management (TIM) in AS patients waiting for TAVI improves the clinical outcomes. In the present article, we report the study protocol of the ResKriVer-TAVI trial. ResKriVer-TAVI will enroll AS patients planned for elective TAVI. Randomization to the TIM group or standard care will be made on the day of the heart team's decision. TIM will include a daily assessment of weight, blood pressure, a 2-channel electrocardiogram, peripheral capillary oxygen saturation, and a self-rated health status until admission for TAVI. TIM will allow optimization of medical therapy or an earlier admission for TAVI if needed. Standard care will not include any additional support for patients with AS. All patients of the TIM group will receive a rule-based TIM including standard operating procedures when a patient is crossing prespecified values of a vital sign. The primary endpoint consists of days lost due to cardiovascular hospitalization and death of any cause within 180 days after the heart team's decision. Major secondary endpoints include all-cause mortality within 365 days, the number of telemedical interventions, and adherence to TIM. Follow-up visits will be conducted at admission for TAVI as well as 6 and 12 months after the heart team's decision. ResKriVer-TAVI will be the first randomized, controlled trial investigating a telemedical approach before TAVI in patients with AS. We hypothesize that primary and secondary endpoints of AS patients with TIM will be superior to standard care. The study will serve to establish TIM in the clinical routine and to increase the resilience of TAVI centers in situations with limited healthcare resources.

Echocardiographic parameters associated with less reverse left ventricular remodeling after transcatheter aortic valve implant in subjects with prosthesis patient mismatch.

Transaortic valve implant (TAVI) is the treatment of choice for severe aortic stenosis (AS). Some patients develop prosthesis patient mismatch (PPM) after TAVI. It is challenging to determine which patients are at risk for clinical deterioration. We retrospectively measured echocardiographic parameters of left ventricular (LV) morphology and function, prosthetic aortic valve effective orifice area (iEOA) and hemodynamics in 313 patients before and 1year after TAVI. Our objective was to compare the change in echocardiographic parameters associated with left ventricular reverse modeling in subjects with and without PPM. Our secondary objective was to evaluate echo parameters associated with PPM and the relationship to patient functional status and survival post-TAVI. We found that 82 (26.2%) of subjects had moderate and 37 (11.8%) had severe PPM post-TAVI. There was less relative improvement in LVEF with PPM (1.9±21.3% vs. 8.2+30.1%, p=.045). LV GLS also exhibited less relative improvement in those with PPM (13.4+34.1% vs. 30.9+73.3%, p=.012). NYHA functional class improved in 84.3% of subjects by one grade or more. Echocardiographic markers of PPM were worse in those without improvement in NYHA class (mean AT/ET was .29 vs. .27, p=.05; DVI was .46 vs. .51, p=.021; and iEOA was .8cm/m2 vs. .9cm/m2 , p=.025). There was no association with PPM and survival. There was no improvement in LVEF and less improvement in LV GLS in those with PPM post-TAVI. Echocardiographic markers of PPM were present in those with lack of improvement in NYHA functional class.

"Postponing it Any Later Would not be so Great": A Cognitive Interview Study of How Physicians Decide to Initiate Goals of Care Discussions in the Hospital.

There are missed opportunities to discuss goals and preferences for care with seriously ill patients in the acute care setting. It is unknown which factors most influence clinician decision-making about communication at the point of care. This study utilized a cognitive-interviewing technique to better understand what leads clinicians to decide to have a goals of care (GOC) discussion in the acute care setting. A convenience sample of 15 oncologists, intensivists and hospitalists were recruited from a single academic medical center in a large urban area. Participants completed a cognitive interview describing their thought process when deciding whether to engage in GOC discussions in clinical vignettes. 6 interconnected factors emerged as important in determining how likely the physician was to consider engaging in GOC at that time; (1) the participants' mental model of GOC, (2) timing of GOC related to stability, acuity and reversibility of the patient's condition, (3) clinical factors such as uncertainty, prognosis and recency of diagnosis, (4) patient factors including age and emotional state, (5) participants' role on the care team, and (6) clinician factors such as emotion and communication skill level. Participants were hesitant to commit to the present moment as the right time for GOC discussions based on variations in clinical presentation. Clinical decision support systems that include more targeted information about risk of clinical deterioration and likelihood of reversal of the acute condition may prompt physicians to discuss GOC, but more support for managing discomfort with uncertainty is also needed.

Prognostic impact of the e-TAPSE ratio in intermediate-high risk pulmonary embolism patients.

We assess the prognostic role of a new index (Age-T index), based on age and the tricuspid annular plane systolic excursion (TAPSE) for the estimation of 30-day mortality and risk of 48-h clinical deterioration since admission, in intermediate-high risk Pulmonary Embolism (PE) patients. A post-hoc analysis of intermediate-high risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. The Age-T index was calculated as the ratio between age and TAPSE. The primary outcome was the 30-day mortality risk while the risk of clinical deterioration within 48h in the same patients was chosen as the secondary outcome. Among 450 intermediate-high risk PE patients (mean age 71.4 ± 13.8 years, 298 males), 40 (8.8%) experienced clinical deterioration within 48h since admission and 32 (7.1%) died within 30-day. Receiver operating characteristic analysis established ≥ 4.9 as the optimal cut-off value for the Age-T index in predicting 30-day mortality (AUC of 0.76 ± 0.1). Sensitivity, specificity, PPV and NPV were 81.2, 85.6, 30.2 and 98.3%, respectively. Multivariate Cox regression analysis showed that an Age-T index ≥ 4.9 predicts 30-day mortality (HR: 3.24, 95% CI: 1.58-4.96, p < 0.001) and was also associated with a significantly higher risk of 48-h clinical deterioration (HR: 2.02, 95% CI 1.96-2.08, p < 0.0001) in intermediate-high risk PE patients. Age-T Index appears as a useful, bed-side and non-invasive prognostic tool to identify intermediate-high risk PE patients at higher risk of death and/or 48-h clinical deterioration.

Adults knowledge and perception of their congenital heart disease: a single center cross-sectional study

Abstract Background A great proportion of patients with congenital heart disease (CHD) reach adulthood and face daily challenges living with a chronic illness. Healthcare management of these patients is complex requiring a multidisciplinary approach. To date, few studies have focused on adult patients’ understanding of their CHD. Aim To assess adults’ knowledge of their CHD on 4 domains: (1) disease and treatment, (2) preventive measures, (3) physical activity, (4) reproductive issues. Methods One single center cross-sectional study. Patients were opportunistically recruited to participate in the study at their CHD medical visit, between October 2022 and December 2022. The authors translated Leuven Knowledge Questionnaire for CHD to Portuguese language. Patients that were willing to participate filled the survey before entering the physician’s room. Demographic and clinical variable were gathered during patients’ interview and from clinical records. After run-in period, data were analyzed in SPSS ® for the descriptive analysis. Categorical values were reported as counts and percentages. Results From a total of 344 patients observed during recruitment period, 97 accepted to participate in the study. Demographic and clinical characteristics of the study population are described in Table 1 and 2. Mean age was 41 years, 60% were female, 34% have an education level above 12th grade and 74% are employed. The 3 most prevalent CHD were Tetralogy of Fallot (16%) and atrial septal defect type secundum (13%) and ventricular septal defect (10%). Approximately half of the patients knew the name of their CHD and 41% could describe or locate the lesion on the pictured diagram. 38% could identify at least two symptoms of clinical deterioration. Three-fourths of patients did not know what endocarditis is and only 14% could tell fever was the main symptom of the disease. The majority of patients did not know the risk factors for endocarditis. 73% of patients are aware that they should choose an occupation adequate to their physical status and 75% knew that they are allowed to engage in sexual intercourse if capable of doing so. Only 20% had adequate knowledge about the hereditary nature of their condition. 43% of women knew the risk of clinical deterioration during pregnancy. Conclusion This study showed our patients have high levels of education and employment. Still, large proportions of adults have lack of knowledge about important issues in vary domains. These findings reinforce the need to improve patients’ education about their disease. In addition, it highlights the importance of guideline recommendations on multidisciplinary teams to achieve high quality of care in adults with CHD.

Validation of the Turkish version of the pediatric early warning score

Aim: The pediatric early warning score (PEWS) identifies pediatric patients at risk for clinical deterioration and can helpless-experienced providers get a sense of which patients may need escalation of care. The purpose of the study was to adapt the PEWS into Turkish and evaluate its validity in pediatric patients admitted to the emergency. &#x0D; Material and Methods: This study was conducted between May and October 2022 on 228 patients aged 17 and under in the pediatric emergency department of a tertiary care hospital. In the pilot phase of the study, scoring of the first 30 patients was performed by three nurses in the emergency department. In the second phase, the validity of the PEWS scale was evaluated. Validity of the scoring system in predicting admission was assessed using area under the receiver operating characteristics (ROC) curve (AUC), sensitivity, and specificity, positive predictive value (PPV) and negative predictive value (NPV).&#x0D; Results: The mean age of the children was 6.37 ± 4.72 years. Phase I demonstrated good inter-rater reliability (kappa = 0.75). In phase II, 22 patients (9.6%) were admitted to the intensive care unit (ICU) during the study period. AUC for predicting was 0.948 (95% CI: 0.915–0.981). According to ROC curve analysis, a cut-off value for PEWS score was found to be 4 (PEWS &gt;4) for admitted to the ICU. Sensitivity and specificity in predicting ICU admission with the cut-off PEWS ≥4 was 86.36% and 90.78%, respectively (PPV, 50%; NPV, 90.48%). The sensitivity and specificity in predicting admission with a cut-off of PEWS ≥1 was 100% and 59.22%, respectively (PPV, 20.75%; NPV, 100%).&#x0D; Conclusion: The Turkish version of PEWS can be helpful in assessing patient status in pediatric emergency department with acceptable validity and can serve as a potentially screening tool for prediction of ICU admission.

Home pulse oximetry monitoring during the COVID-19 pandemic: An assessment of patient engagement and compliance

ObjectivesPatients with suspected COVID-19 remain at risk for clinical deterioration after discharge and may benefit from home oxygen saturation (SpO2) monitoring using portable pulse oximeter devices. Our study aims to evaluate patient engagement and compliance with a home SpO2 monitoring program. MethodsThis is a single center, prospective pilot study of patients being discharged from the ED or urgent care after evaluation of symptoms consistent with COVID-19. Subjects were given a portable pulse oximeter and instructed to obtain measurements at rest and with exertion twice daily for 14 days. Patients were contacted daily to collect recorded data. If attempts to contact the patient were unsuccessful for 3 consecutive days, patients were considered lost to follow up. The primary outcome of interest was patient engagement in the program which was defined as the percentage of patients that completed the 14-day study period, meaning they were not lost to follow up. Secondary outcomes included compliance with performing the SpO2 readings. Patient compliance was calculated as a percentage of completed readings out of the total expected readings. ResultsFifty patients were enrolled - 2 withdrew and 1 was a screen failure. Overall, engagement in the program was 46.8% with no significant difference between those who tested positive for SARS-CoV-2 versus those who tested negative (48.2% vs 45%, p = 0.831). Median compliance overall was 42.9% (IQR 22.22–78.57). Median compliance for the positive group was 50.0% (IQR 20–85.71) and 42.86% (IQR 22.92–76.44) for the negative group (p = 0.838). ConclusionOur study demonstrated that there was acceptable engagement and compliance in a 14-day home SpO2 monitoring program. These results support the use of home pulse oximetry monitoring in a select group of mildly ill patients with suspected COVID-19.

Clinical features of snake envenomation in South Korea

Introduction Three venomous snakes of the Gloydius genus belonging to the Viperidae family cause most snake envenomations in South Korea. Envenomation signs often include local swelling, coagulopathy, and rhabdomyolysis. The benefit of additional antivenom after the initial does is unclear. Methods This retrospective study divided patients into four groups according to the presence of rhabdomyolysis (creatine kinase ≥1000 IU/L) and coagulopathy, which were defined using the Korean Society on Thrombosis and Hemostasis disseminated intravascular coagulation score (rhabdomyolysis, coagulopathy, combination, and local effects groups). We describe the clinical features of envenomation and the antivenom response. Results Greater local swelling predicted more severe snakebite pain. Ninety of the 231 enrolled patients (38.9%) developed rhabdomyolysis. The patients with severe rhabdomyolysis in the combination group displayed higher peak creatine kinase activity than the rhabdomyolysis group. Seven patients with rhabdomyolysis, including two patients requiring kidney replacement therapy, developed acute kidney injury, but the incidence of acute kidney injury did not differ between the combination group and rhabdomyolysis group. Bleeding developed in 3.5% of the patients, but its incidence did not differ between the combination and coagulopathy groups. Approximately half of all patients needed repeated antivenom administration, mainly due to the local envenomation effect. Earlier administration of additional antivenom for progressive local swelling did not reduce the hospitalization duration. Conclusion Rhabdomyolysis is one of the major effects of Gloydius snake envenomation in South Korea, although it is not associated with the same risk of clinical deterioration as coagulopathy. Additionally, the ability of antivenom to ameliorate local swelling should be investigated to prevent unnecessary antivenom administration in South Korea.

The Deterioration Risk Index: Developing and Piloting a Machine Learning Algorithm to Reduce Pediatric Inpatient Deterioration.

Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program. Retrospective cohort study. Nationwide Children's Hospital, a freestanding, quaternary-care, academic children's hospital in Columbus, OH. All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization. We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021. The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001). The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.

Metalloproteinases and Tissue Inhibitors in Generalized Myasthenia Gravis. A Preliminary Study.

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have recently been proposed as promising biomarkers in different immune-mediated disorders. We evaluated the plasma levels of MMP-9 and MMP-2 and their tissue inhibitors TIMP-1 and TIMP-2 in a patients' cohort with generalized myasthenia gravis (MG). Plasma concentrations of MMP-9, MMP-2, TIMP-1 and TIMP-2 were evaluated in 14 patients with generalized MG and 13 age- and sex-matched healthy controls. The severity of disease was assessed by the modified Osserman classification. Compared to the healthy subjects, MG patients had increased plasma concentrations of MMP-9, but reduced plasma levels of MMP-2 and TIMP-1. MG patients also showed a positive correlation between MMP-2 concentrations and disease severity. An increase in MMP-9 levels and MMP-9/TIMP-1 ratio and a decrease in MMP-2 levels and MMP-2/TIMP-2 ratio were detected in patients with generalized MG. Higher levels of MMP-2 correlated with greater disease severity. Our preliminary findings suggest that MMPs and TIMPs could play a role in the pathogenesis of MG and might be associated with the risk of clinical deterioration.

PROGNOSTIC VALUE OF NONINVASIVE EXERCISE CARDIAC INDEX MEASUREMENTS IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION

SESSION TITLE: PAH Abstract PostersSESSION TYPE: Original Investigation PostersPRESENTED ON: 10/18/2022 01:30 pm - 02:30 pmPURPOSE: Background: Patients with pulmonary arterial hypertension (PAH) have a reduced ability to increase cardiac index (CI) in response to exercise due to impaired right ventricular reserve. Whether this impaired CI augmentation correlates with quality of life (QoL), or the risk of clinical deterioration in PAH is unknown. Impedance cardiography (ICG) can accurately and noninvasively measure CI in PAH.Research Question:In patients with PAH, does the change in CI (ΔCI) with exercise, assessed with ICG, predict clinical worsening at 1 year?METHODS: Study Design & Methods: Patients with WHO Group 1 PAH were recruited and performed a 6MWT according to ATS standards. A Noninvasive Cardiac System (NICaS, NIMedical) ICG was used to measure the cardiac index at rest and immediately post-test. The primary analysis will be the association between ΔCI and clinical worsening at 1-year. This interim analysis describes the association between ΔCI and 6MWD, QoL (using emPHasis-10 score), and REVEAL 2.0 risk score using Pearson correlation.RESULTS: 19 patients completed the 6MWT (mean±SD: age 60±12 years, disease duration 37±30 months, number of PAH-targeted therapies 1.9±0.8). Mean resting CI was 2.72±0.5 L/min/m2. Following the 6MWT, the mean increase in CI was 1.36±1.09 L/min/m2 (range -0.02-3.03 L/min/m2), due to increases in heart rate (13.2±11.4bpm, range -1 to 41bpm) and stroke volume (9.5±10.1ml, range -2-22.7ml). ΔCI was not associated with walk distance (r=0.26, p=0.14), REVEAL 2.0 risk score (r=0.12, p=0.33), or emPHasis-10 (r=0.24, p=0.16). CI at end-exercise was associated with walk distance (r=0.41, p=0.039). A greater heart rate augmentation was associated with poorer quality of life (r=0.41,p=0.039) and higher-risk REVEAL score (r=0.44,p=0.029), although this was not explained by a compensatory increase for impaired stroke volume augmentation.CONCLUSIONS: Interpretation: In PAH, the change in cardiac index with exercise was not associated with 6MWD, NT-pro-BNP, QoL, or clinical risk score. Greater tachycardia with exercise was associated with worse QoL and clinical risk score. A 1-year follow-up is planned to determine whether ΔCI has any potential role in predicting PAH progression.CLINICAL IMPLICATIONS: TBDDISCLOSURES: No relevant relationships by Lauren BathNo relevant relationships by David ChristiansenNo relevant relationships by Ashish Shah SESSION TITLE: PAH Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Background: Patients with pulmonary arterial hypertension (PAH) have a reduced ability to increase cardiac index (CI) in response to exercise due to impaired right ventricular reserve. Whether this impaired CI augmentation correlates with quality of life (QoL), or the risk of clinical deterioration in PAH is unknown. Impedance cardiography (ICG) can accurately and noninvasively measure CI in PAH. Research Question:In patients with PAH, does the change in CI (ΔCI) with exercise, assessed with ICG, predict clinical worsening at 1 year? METHODS: Study Design & Methods: Patients with WHO Group 1 PAH were recruited and performed a 6MWT according to ATS standards. A Noninvasive Cardiac System (NICaS, NIMedical) ICG was used to measure the cardiac index at rest and immediately post-test. The primary analysis will be the association between ΔCI and clinical worsening at 1-year. This interim analysis describes the association between ΔCI and 6MWD, QoL (using emPHasis-10 score), and REVEAL 2.0 risk score using Pearson correlation. RESULTS: 19 patients completed the 6MWT (mean±SD: age 60±12 years, disease duration 37±30 months, number of PAH-targeted therapies 1.9±0.8). Mean resting CI was 2.72±0.5 L/min/m2. Following the 6MWT, the mean increase in CI was 1.36±1.09 L/min/m2 (range -0.02-3.03 L/min/m2), due to increases in heart rate (13.2±11.4bpm, range -1 to 41bpm) and stroke volume (9.5±10.1ml, range -2-22.7ml). ΔCI was not associated with walk distance (r=0.26, p=0.14), REVEAL 2.0 risk score (r=0.12, p=0.33), or emPHasis-10 (r=0.24, p=0.16). CI at end-exercise was associated with walk distance (r=0.41, p=0.039). A greater heart rate augmentation was associated with poorer quality of life (r=0.41,p=0.039) and higher-risk REVEAL score (r=0.44,p=0.029), although this was not explained by a compensatory increase for impaired stroke volume augmentation. CONCLUSIONS: Interpretation: In PAH, the change in cardiac index with exercise was not associated with 6MWD, NT-pro-BNP, QoL, or clinical risk score. Greater tachycardia with exercise was associated with worse QoL and clinical risk score. A 1-year follow-up is planned to determine whether ΔCI has any potential role in predicting PAH progression. CLINICAL IMPLICATIONS: TBD DISCLOSURES: No relevant relationships by Lauren Bath No relevant relationships by David Christiansen No relevant relationships by Ashish Shah

Modified Early Warning Score vs Cardiac Arrest Risk Triage Score for Prediction of Cardiopulmonary Arrest: A Case-Control Study.

Delayed transfer to the intensive care unit (ICU) contributes to increased mortality. Clinical tools, developed to shorten this delay, are especially useful in hospitals where the ideal healthcare provider-to-patient ratio is not met. This study aimed to validate and compare the accuracy of the well-accepted modified early warning score (MEWS) and the newer cardiac arrest risk triage (CART) score in the Philippine setting. This case-control study involved 82 adult patients admitted to the Philippine Heart Center. Patients who had cardiopulmonary (CP) arrest at the wards and those transferred to the ICU were included. Vital signs and alert-verbal-pain-unresponsive (AVPU) scales were recorded from recruitment until 48 hours prior to CP arrest or ICU transfer. The MEWS and CART scores were computed at specific time points and compared using measures of validity. The highest accuracy was obtained by the CART score with a cut-off of ≥12 at 8 hours prior to CP arrest or ICU transfer, with a specificity of 80.43% and sensitivity of 66.67%. At this time point, the MEWS with a cut-off of ≥3 had a specificity of 78.26% but a lower sensitivity of 58.33%. The area under the curve (AUC) analysis revealed that these differences were not statistically significant. We recommend an MEWS threshold of 3 and a CART score threshold of 12 to help identify patients at risk for clinical deterioration. The CART score had comparable accuracy to the MEWS, but the latter's computation may be easier. Tan ADA, Permejo CC, Torres MCD. Modified Early Warning Score vs Cardiac Arrest Risk Triage Score for Prediction of Cardiopulmonary Arrest: A Case-Control Study. Indian J Crit Care Med 2022;26(7):780-785.

Machine Learning-Based Systems for the Anticipation of Adverse Events After Pediatric Cardiac Surgery.

Pediatric congenital heart disease (CHD) patients are at higher risk of postoperative complications and clinical deterioration either due to their underlying pathology or due to the cardiac surgery, contributing significantly to mortality, morbidity, hospital and family costs, and poor quality of life. In current clinical practice, clinical deterioration is detected, in most of the cases, when it has already occurred. Several early warning scores (EWS) have been proposed to assess children at risk of clinical deterioration using vital signs and risk indicators, in order to intervene in a timely manner to reduce the impact of deterioration and risk of death among children. However, EWS are based on measurements performed at a single time point without incorporating trends nor providing information about patient's risk trajectory. Moreover, some of these measurements rely on subjective assessment making them susceptible to different interpretations. All these limitations could explain why the implementation of EWS in high-resource settings failed to show a significant decrease in hospital mortality. By means of machine learning (ML) based algorithms we could integrate heterogeneous and complex data to predict patient's risk of deterioration. In this perspective article, we provide a brief overview of the potential of ML technologies to improve the identification of pediatric CHD patients at high-risk for clinical deterioration after cardiac surgery, and present the CORTEX traffic light, a ML-based predictive system that Sant Joan de Déu Barcelona Children's Hospital is implementing, as an illustration of the application of an ML-based risk stratification system in a relevant hospital setting.

PB2270: CLEARANCE OF PERSISTENT SARS-COV2 INFECTION WITH ANTIBODY CONTAINING PLASMA IN LEUKEMIA AND LYMPHOMA PATIENTS

Background: Patients with hematological malignancies or other reasons for inadequate immune response are at high risk for poor outcome of COVID-19 disease. In addition, a significant fraction of patients unable to mount an antibody response fail to clear SARS-Cov2 virus putting them at risk for clinical deterioration. Also, persistent COVID-19 infection impedes further treatment of the underlying disease. So far, no treatment has been established for persistent COVID-19 infection in immunocompromised patients. Aims: Here, we treated eight immunocompromised patients with active SARS-COV2 infection with plasma from convalescent or/and vaccinated donors in a case series of individual treatments. Methods: Patients were eligible for treatment if active SARS-Cov2 infection was confirmed at least 14 days after initial detection. In two out of eight patients sequencing results confirmed the omicron variant. Therapies before plasma treatment included antivirals and monoclonal antibodies. Underlying diseases were B-ALL (n=3; including one patient after allogeneic stem cell transplantation), multiple myeloma (n=2), lymphoma (n=2) and immunosuppression after kidney transplantation (n=1). Median age was 48 years (range 7 – 78). Antibody containing plasma was obtained from healthy donors either after confirmed SARS-COV2 infection or after mRNA vaccination. Overall, 22 treatment cycles were administered in 8 patients (median 2, range 1 to 7). For each patient the available plasma with the highest titers of neutralizing antibodies and matching blood type was administered. Results: Neutralizing antibody titers in plasma were median 1:320 (range 1:40 to 1:2560). Titers of neutralizing antibodies in convalescent plasma (n=10 treatments; median titer: 1:80) were lower than in vaccinated donor plasma (median 1:320; p=0.058, Mann-Whitney U test) (n=12 treatments). Median Ct-values of viral load before treatment were 20.5 (range 14.9 to 37.3). After treatment (median 5 days), the Ct-values changed to median 26.9 (range 19.5 to non-detectable). The median fold decrease in viral load was estimated to be 127-fold with a range from 0.8 to >2x104 (p<10-4, paired t-test). Similar reductions in viral load were achieved after administration of either plasma from convalescent (median 109) or vaccinated donors. SARS-COV2 virus was cleared in 7 of 8 (87.5%) patients with ongoing treatment in one patient. No specific adverse events were observed. Figure 1: Fold reduction in viral load after a single treatment with anti-SARS-COV2 containing plasma. Image:Summary/Conclusion: Plasma with high titers of neutralizing SARS-COV2 antibodies can clear persistent infection in patients with hematological malignancies and immunocompromised patients. Plasma obtained either from convalescent patients or vaccinated donors might constitute an effective and inexpensive treatment in this situation.

MO985: Physical Function Trajectories Predict Patient Survival in Older Recipients of Deceased Donor Kidneys

Abstract BACKGROUND AND AIMS Health-related quality of life (HRQOL) outcomes have been positively associated with patient survival after kidney transplantation (KT). In older recipients, poor HRQOL may indicate risk for clinical deterioration. We aimed to prospectively evaluate if, in older recipients of deceased brain-dead donor (DBD) kidneys, changes in HRQOL during the first year post-transplantation differed between survivor and non-survivors. METHOD KT candidates aged ≥65 years who were enlisted between January 2013 and November 2016 at the Norwegian national transplant center and received a deceased brain-dead donor (DBD) kidney were included. HRQOL was assessed using the Kidney Disease Quality of Life Short Form, version 1.3. HRQOL outcomes were collected prior to KT, at 10 weeks, 6 months and 12 months post-KT. A mixed-effect linear regression model was used to examine the development of HRQOL during the first year post-KT in survivors versus non-survivors. Longitudinal HRQOL trajectories were identified using a group-based trajectory modelling. A Cox proportional hazard regression was used to investigate the association of longitudinal HRQOL trajectories for each domain with patient survival. RESULTS We included 289 waitlisted candidates, of whom 192 received a DBD kidney. Mean age at KT was 72 (4.1) years, 133 (69%) were males, 47 (24%) were transplanted preemptively and 80% received an expanded criteria donor organ. During a median observation time of 4.6 (3.2, 6.3) years post-KT, 66 recipients died. In survivors, all the generic and kidney-specific HRQOL domains substantially improved during the first year post-KT, whereas HRQOL deteriorated in non-survivors (Figure 1). Three developmental trajectories, describing poor, fair and good outcomes were identified for most of the HRQOL domains. Recipients perceiving poor physical development during the first post-transplant year had a 2.5 higher mortality risk, while recipients with fair physical development had 1.4 increased mortality risk, compared with recipients with good physically development (Figure 2). CONCLUSION In elderly kidney transplant recipients, poor post-transplant physical function trajectory may indicate impaired survival. The systematic HRQOL monitoring following KT is warranted to identify high-risk patients and guide therapeutic decisions.

Comparison of early warning scores for predicting clinical deterioration and infection in obstetric patients

BackgroundEarly warning scores are designed to identify hospitalized patients who are at high risk of clinical deterioration. Although many general scores have been developed for the medical-surgical wards, specific scores have also been developed for obstetric patients due to differences in normal vital sign ranges and potential complications in this unique population. The comparative performance of general and obstetric early warning scores for predicting deterioration and infection on the maternal wards is not known.MethodsThis was an observational cohort study at the University of Chicago that included patients hospitalized on obstetric wards from November 2008 to December 2018. Obstetric scores (modified early obstetric warning system (MEOWS), maternal early warning criteria (MEWC), and maternal early warning trigger (MEWT)), paper-based general scores (Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS), and a general score developed using machine learning (electronic Cardiac Arrest Risk Triage (eCART) score) were compared using the area under the receiver operating characteristic score (AUC) for predicting ward to intensive care unit (ICU) transfer and/or death and new infection.ResultsA total of 19,611 patients were included, with 43 (0.2%) experiencing deterioration (ICU transfer and/or death) and 88 (0.4%) experiencing an infection. eCART had the highest discrimination for deterioration (p < 0.05 for all comparisons), with an AUC of 0.86, followed by MEOWS (0.74), NEWS (0.72), MEWC (0.71), MEWS (0.70), and MEWT (0.65). MEWC, MEWT, and MEOWS had higher accuracy than MEWS and NEWS but lower accuracy than eCART at specific cut-off thresholds. For predicting infection, eCART (AUC 0.77) had the highest discrimination.ConclusionsWithin the limitations of our retrospective study, eCART had the highest accuracy for predicting deterioration and infection in our ante- and postpartum patient population. Maternal early warning scores were more accurate than MEWS and NEWS. While institutional choice of an early warning system is complex, our results have important implications for the risk stratification of maternal ward patients, especially since the low prevalence of events means that small improvements in accuracy can lead to large decreases in false alarms.

One-on-one comparison between qCSI and NEWS scores for mortality risk assessment in patients with COVID-19

Objective To compare the predictive value of the quick COVID-19 Severity Index (qCSI) and the National Early Warning Score (NEWS) for 90-day mortality amongst COVID-19 patients. Methods Multicenter retrospective cohort study conducted in adult patients transferred by ambulance to an emergency department (ED) with suspected COVID-19 infection subsequently confirmed by a SARS-CoV-2 test (polymerase chain reaction). We collected epidemiological data, clinical covariates (respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature, level of consciousness and use of supplemental oxygen) and hospital variables. The primary outcome was cumulative all-cause mortality during a 90-day follow-up, with mortality assessment monitoring time points at 1, 2, 7, 14, 30 and 90 days from ED attendance. Comparison of performances for 90-day mortality between both scores was carried out by univariate analysis. Results From March to November 2020, we included 2,961 SARS-CoV-2 positive patients (median age 79 years, IQR 66–88), with 49.2% females. The qCSI score provided an AUC ranging from 0.769 (1-day mortality) to 0.749 (90-day mortality), whereas AUCs for NEWS ranging from 0.825 for 1-day mortality to 0.777 for 90-day mortality. At all-time points studied, differences between both scores were statistically significant (p < .001). Conclusion Patients with SARS-CoV-2 can rapidly develop bilateral pneumonias with multiorgan disease; in these cases, in which an evacuation by the EMS is required, reliable scores for an early identification of patients with risk of clinical deterioration are critical. The NEWS score provides not only better prognostic results than those offered by qCSI at all the analyzed time points, but it is also better suited for COVID-19 patients. KEY MESSAGES This work aims to determine whether NEWS is the best score for mortality risk assessment in patients with COVID-19. AUCs for NEWS ranged from 0.825 for 1-day mortality to 0.777 for 90-day mortality and were significantly higher than those for qCSI in these same outcomes. NEWS provides a better prognostic capacity than the qCSI score and allows for long-term (90 days) mortality risk assessment of COVID-19 patients.

A machine learning model for predicting deterioration of COVID-19 inpatients

The COVID-19 pandemic has been spreading worldwide since December 2019, presenting an urgent threat to global health. Due to the limited understanding of disease progression and of the risk factors for the disease, it is a clinical challenge to predict which hospitalized patients will deteriorate. Moreover, several studies suggested that taking early measures for treating patients at risk of deterioration could prevent or lessen condition worsening and the need for mechanical ventilation. We developed a predictive model for early identification of patients at risk for clinical deterioration by retrospective analysis of electronic health records of COVID-19 inpatients at the two largest medical centers in Israel. Our model employs machine learning methods and uses routine clinical features such as vital signs, lab measurements, demographics, and background disease. Deterioration was defined as a high NEWS2 score adjusted to COVID-19. In the prediction of deterioration within the next 7–30 h, the model achieved an area under the ROC curve of 0.84 and an area under the precision-recall curve of 0.74. In external validation on data from a different hospital, it achieved values of 0.76 and 0.7, respectively.

LUNG ULTRASOUND AS AN EMERGENCY TRIAGE TOOL IN PATIENTS DIAGNOSED WITH COVID-19

COVID-19 is a widespread disease in 2020. The goal of this study is to determine the sonographic characteristics of 105 individuals brought to the ER with COVID-19. Lung Ultrasound was performed by two doctors on each patient then compared to CT Scan Findings. Our study found that Lung ultrasound is a good tool for identifying patients at higher risk of clinical deterioration, ICU admission, mechanical ventilation and mortality. Lung ultrasound can be used in settings where CT Scan is not available.

Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study

BackgroundOlder people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously.MethodsIn this study, video-telehealth consultation was added to an existing program, the Aged Care Emergency (ACE) program, aiming at further reducing Emergency Department (ED) visits and hospital admissions. This controlled pre-post study introduced video-telehealth consultation as an additional component to the ACE program for acutely unwell residents in RACs. Usual practice is for RACs and ACE to liaise via telephone. During the study, when the intervention RACs called the ED advanced practice nurse, video-telehealth supported clinical assessment and management. Five intervention RACs were compared with eight control RACs, all of whom refer to one community hospital in regional New South Wales, Australia. Fourteen months pre-video-telehealth was compared with 14 months post-video-telehealth using generalized linear mixed models for hospital admissions after an ED visit and ED visits. One thousand two hundred seventy-one ED visits occurred over the 28-month study period with 739 subsequent hospital admissions.ResultsThere were no significant differences in hospital admission or ED visits after the introduction of video-telehealth; adjusted incident rate ratios (IRR) were 0.98 (confidence interval (CI) 0.55 to 1.77) and 0.89 (95% CI 0.53 to 1.47) respectively.ConclusionsVideo-telehealth did not show any incremental benefit when added to a structured hospital avoidance program with nursing telephone support.Trial registrationThe larger Aged Care Emergency evaluation is registered with ANZ Clinical Trials Registry, ACTRN12616000588493.