Subsequent Intensive Care Unit Admission Research Articles

Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis

Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown. To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission. This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024. Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey. Proportion of patients with bronchiolitis admitted to the ICU. A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups. Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

Triage of Critically Ill Patients: Characteristics and Outcomes of Patients Refused as Too Well for Intensive Care.

The appropriate selection of patients for the intensive care unit (ICU) is a concern in acute care settings. However, the description of patients deemed too well for the ICU has been rarely reported. We conducted a single-centre retrospective observational study of all patients either deemed "too well" for or admitted to the ICU during one year. Refused patients were screened for unexpected events within 7 days, defined as either ICU admission without another indication, or death without treatment limitations. Patients' characteristics and organisational factors were analysed according to refusal status, outcome and delay in ICU admission. Among 2219 enrolled patients, the refusal rate was 10.4%. Refusal was associated with diagnostic groups, treatment limitations, patients' location on a ward, night time and ICU occupancy. Unexpected events occurred in 16 (6.9%) refused patients. A worse outcome was associated with time spent in hospital before refusal, patients' location on a ward, SOFA score and physician's expertise. Delayed ICU admissions were associated with ICU and hospital length of stay. ICU triage selected safely most patients who would have probably not benefited from the ICU. We identified individual and organisational factors associated with ICU refusal, subsequent ICU admission or death.

Renin-angiotensin-aldosterone system blockers in Bulgarian COVID-19 patients with or without chronic kidney disease

When angiotensin-converting enzyme inhibitor/angiotensin receptor blocker-treated patients present with SARS-CoV-2 infection there is a debate to know whether renin-angiotensin-aldosterone (RAAS) blockers should be stopped or not. We conducted a prospective observational study in Bulgarian COVID-19-infected patients with or without chronic kidney disease (CKD) to assess whether maintenance RAAS blocker therapy has an impact on SARS-CoV-2 infection and its complications. We included 120 in-patient COVID-19 subjects, of whom 70 had CKD and 50 had normal renal function. A total of 30% of the patients (total number of 36 patients, 21 females) were receiving RAAS therapy at admission and it was maintained throughout hospitalization. The overall mortality was 19.2% (23 patients); there was no significant difference across the 2 groups (P-value = .21), except in RAAS blockers-treated hypertensive patients who had a significantly lower mortality as compared to non-RAAS-blockers-treated hypertensive patients (P = .04). Regarding subsequent intensive-care unit admission, there were 50% less patients in the RAAS group (4 out of 36, i.e., 11%) as compared to 19 out of 84 from the non-RAAS group, that is, 22.6% (P = .29). Overall, 37 patients developed acute kidney injury (any stage by KDIGO); of them 14 (37.8%) were receiving RAAS blockers. Acute kidney injury was not significantly associated with the use of RAAS blockers (P-value = .28). Likewise, both in non-CKD and in CKD patients the use of RAAS blockers did not have an impact on renal function recovery after SARS-CoV-2 infection. Finally, regarding RAAS blockers and the biological parameters outcome only D-dimers were significantly lower at the follow-up as compared to that in non-RAAS blocker treated patients. RAAS blockers benefited patients with hypertension by lowering mortality rate. Other than that, RAAS blocker therapy continuation during SARS-CoV-2 infection in CKD and non-CKD patients had no significant impact upon major outcomes.

Risk factors for unplanned paediatric intensive care unit admission after anaesthesia-an international multicentre study.

Unplanned intensive care unit (ICU) admissions are associated with near-miss events, morbidity, and mortality. We describe the rate, resource utilization, and outcomes of paediatric patients urgently admitted directly to ICU post-anaesthesia compared to other sources of unplanned ICU admissions. We performed a secondary analysis of data from specialist paediatric hospitals in 7 countries. Patients urgently admitted to the ICU post-anaesthesia were combined and matched with 1 to 3 unique controls from unplanned ICU admissions from other locations by age and hospital. Demographic, clinical, and outcome variables were compared using the Wilcoxon rank-sum test for continuous variables and chi-square or Fisher's exact test for categorical variables. The effect of admission sources on binary outcomes was estimated using univariable conditional logistic regression models with stratification by matched set of anaesthesia and non-anaesthesia admission sources. Most admissions were <1 year of age and for respiratory reasons. Admissions post-anaesthesia were shorter, occurred later in the day, and were more likely to be mechanically ventilated. Admissions post-anaesthesia were less likely to have had a previous ICU admission (4.8% compared to 11%, P=0.032) or PIM 'high-risk diagnosis' (9.5% versus 17.2%, P=0.035) but there was no difference in the number of subsequent ICU admissions. There was no difference in the PIM severity of illness score and no mortality difference between the groups. Young children and respiratory indications dominated unplanned ICU admissions post-anaesthesia, which was more likely later in the day and with mechanical ventilation.

PP259 Invisible Resilience: The Value Of Medical Technology In Reducing Population And Health Systems’ Vulnerability To COVID-19.

IntroductionCOVID-19 has exposed population and health systems’ vulnerability to a highly infectious disease. People with diabetes have a higher risk of COVID-19 hospitalization and death than those without. Medicines that control blood glucose reduce this risk. We quantified COVID-19 hospital admissions and deaths averted by diabetes medicines in the UK during the March-May 2020 wave.MethodsWe estimated COVID-19 hospital and intensive care unit (ICU) admissions averted and COVID-19 hospital deaths avoided by diabetes medicines, considering a counterfactual where those medicines were not available. We used published UK-data sources on diabetes prevalence, proportion of patients achieving diabetes control with medicines, COVID-19 infection risk, probabilities for COVID-19 hospital admission, subsequent ICU admission and hospital death. We calculated the relative risk reduction of controlled vs. uncontrolled diabetes on COVID-19 hospital or ICU admission (71% and 66%, respectively), and hospital death (38%) from the UK Open Safely data.ResultsDiabetes medicines are estimated to have averted 17,417 hospital admissions, 2,752 ICU-admissions and 438 hospital deaths due to COVID-19 compared to a counterfactual where those medicines had not been available in the UK.ConclusionsEffective medicines to control diabetes contribute to population and health systems resilience against COVID-19. Health technology assessment and policy makers should recognize that adoption and usage of health technology reduces societies’ vulnerability to similar shocks.

A critical decision point: Short- and long-term outcomes of older surgical patients admitted to a Queensland intensive care unit.

Critical care admission is a pivotal juncture for older patients undergoing surgery. We aimed to identify the in-hospital and postdischarge outcomes of older postsurgical patients (≥65years) admitted to the intensive care unit (ICU). We collected clinical, morbidity and survival data on all patients aged ≥65years postsurgically admitted to a tertiary metropolitan ICU between 2014 and 2019. Within this older cohort (n=370), the oldest patients (≥85years) had the highest 1-year mortality (RR: 4.00; P<0.001). Major surgery (RR: 5.67; P<0.001), emergency surgery (RR: 2.89; P<0.001) and APACHE III score ≥50 (RR: 2.63; P<0.001) were associated with reduced 1-year survival. APACHE III score and surgery subtype are strong predictors of post-ICU mortality and may be useful to preoperatively stratify whether surgery and subsequent ICU admission are in patients' best interests. These data may also inform prospective discussions regarding end-of-life care and advanced care planning.

Implications of intensive care unit admissions among medicare beneficiaries following resection of pancreatic cancer.

Intensive care unit (ICU) use has increased among patients with cancer. We sought to define factors associated with ICU admissions among patients with pancreatic cancer and characterize trends in mortality among hospital survivors. The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was used to identify patients with pancreatic cancer who underwent resection. Multivariable analyses were conducted to identify factors associated with ICU admission and mortality among hospital survivors. Among 6422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2386 (37.1%) had an ICU admission. Patients with ICU admissions were more likely to be younger (10-year increase odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.77-0.89), male (OR: 1.17, 95% CI 1.05-1.30) and undergo resection at a teaching hospital (OR: 1.19, 95% CI: 1.05-1.36). While the majority of patients survived to hospital discharge (n = 2106; 88.3%), a majority of patients (n = 1296; 54.3%) died within 6 months. Among patients who had subsequent ICU admissions, 1- and 5-year survival was only 31.8% and 11.0%, respectively. Over one-third of patients with pancreatic cancer had an ICU admission. While most patients survived hospitalization, more than one-half of patients died within 6 months of discharge and two-thirds died within 1 year. These data should serve to guide patient-provider discussions around prognosis relative to ICU utilization.

Sensitivity and Specificity of prior Methicillin-Resistant Staphylococcus aureus Nasal Swab Results for Predicting Methicillin-Resistant Staphylococcus aureus Infections in Intensive Care Unit Admissions Over a 1-Year Period: A Pilot Study.

Objective:Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a pathogen worldwide. Empiric anti-MRSA therapy is often prescribed in hospital inpatients with potential infection. Recent studies have suggested, particularly for respiratory infections, that MRSA colonization as determined by nasal swab has a high negative predictive value (NPV) for MRSA infections during the index hospitalization. We examined the predictive value of a prior intensive care unit (ICU) MRSA nasal swab on the results from a subsequent ICU admission in the same patient and the results of the latter admission MRSA nasal swab.Methods:A retrospective chart review of patients 18 years or older admitted to a large tertiary care hospital in the Midwest of the United States in 2016 who had a MRSA nasal swab performed and had an ICU admission stay of over 24 h was conducted. This group of patients was matched to a patient list of subjects who were admitted as an inpatient to the same ICU at least once during the following year. Data were collected on demographic and clinical information, as well as the results of MRSA swabs and the presence of a MRSA infection during both hospitalizations. Predictive values were calculated using 2 × 2 tables including sensitivity and specificity of a first MRSA swab result with a MRSA infection during the subsequent ICU stay.Findings:Seventy-seven patients were matched who had MRSA swabs performed on two separate ICU admissions. The negative predictive value of the first MRSA swab result on a MRSA infection during the second ICU stay was 96%.Conclusion:In this pilot study, a previous negative MRSA nasal swab may predict a lack of a MRSA infection in a subsequent infection during a 1-year period.

Clinical burden of ICU admission among patients undergoing resection of pancreatic cancer

Presenter: Daniel Rice BS | The Ohio State University Background: Pancreatic adenocarcinoma is a leading cause of cancer-related deaths in the United States. Intensive care unit (ICU) utilization has increased among patients with cancer, and ICU utilization may be more common among surgical patients with cancer – especially among individuals undergoing complex operative procedures such as pancreatectomy. We sought to define disease and demographic factors associated with ICU admissions among patients with pancreatic cancer, as well as characterize trends in mortality among hospital ICU survivors. Methods: The Surveillance, Epidemiology, and End Results (SEER) – Medicare linked database was used to identify patients with a diagnosis of pancreatic cancer who underwent resection between 2004-2015. Multivariable analyses were conducted to identify factors associated with subsequent ICU admission, as well as mortality among hospital survivors. Results: Among 6,422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2,386 (37.1%) had an ICU admission following surgery; ICU utilization was most common at the time of the index surgical hospitalization (n=4,646; 72.3%). Patients with an ICU admission were more likely to be younger (10-year increase OR 0.83, 95%CI 0.77-0.89), male (OR 1.17, 95%CI 1.05-1.30) and undergo resection at a teaching hospital (OR 1.19, 95%CI 1.05-1.36). Among patients who had an ICU admission, while the majority of patients survived to hospital discharge (n= 2,106; 88.3%), a large subset of patients (n=1,296; 54.3%) died within 6 months. In fact, among patients who underwent pancreatic resection and had a subsequent ICU admission, 1- and 5-year overall survival was only 31.8% and 11.0%, respectively. Ventilatory support during ICU admission was associated with marked increased odds of in-hospital mortality (OR 5.67; 95%CI 3.05-10.56); however, among patients who survived to discharge, history of ICU ventilatory support was not associated with 6-month (OR 1.81; 95%CI 0.77-4.26), 1- (OR 1.19; 95%CI 0.50-2.86) or 5-year (OR 1.01, 95%CI 0.29-3.41) survival (all p>0.05). Outcomes following ICU admission did not vary over the last decade. Specifically, among patients who underwent pancreatectomy, the proportion of patients who survived 6-months and 1-year from discharge following an ICU admission was 35.5% and 23.4% in 2004 versus 41.9% and 28.5% in 2015, respectively (both p>0.05)(Figure). Following an ICU admission, patients discharged with home health care (OR 1.48, 95%CI 1.17-1.86) or to a skilled nursing facility (OR 1.91, 95%CI 1.43-2.54) had higher risk of death within a year of discharge versus patients discharged home with self-care (both p<0.05). Conclusion: Over 1 in 3 patients with pancreatic cancer who underwent surgical resection had at least one subsequent ICU admission. While most patients survived the hospitalization, more than one-half of the patients died within 6 months of discharge and two-thirds died within 1-year of discharge. These data should serve to guide patient-provider discussions around prognosis relative to ICU use among patients with pancreatic cancer undergoing resection.

Antibody Development and Disease Severity of Covid-19 in Non-Immunized Patients with Rheumatic Immune-Mediated Inflammatory Diseases: Data from a Prospective Cohort Study

Background: Research on the disease severity of COVID-19 in patients with rheumatic immune-mediated inflammatory diseases (IMIDs) has been inconclusive, and long-term prospective data on the development of SARS-CoV-2 antibodies in these patients are lacking. We conducted an investigator-driven prospective cohort study to compare the disease severity of COVID-19, and the development of SARS-CoV-2 antibodies over time between patients with rheumatic IMIDs and healthy controls.Methods: Adult patients with rheumatic IMIDs from the Amsterdam Rheumatology & immunology Center, Amsterdam were invited to participate. All patients were asked to recruit their own sex- and age-matched control subject. We developed a new platform for collecting clinical data in large patient groups with online questionnaires (at baseline, and after 1-4 and 5-9 months of follow-up). Serum samples were collected two times during follow-up; after completing the follow-up questionnaires and prior to COVID-19 vaccination. All serum samples were analyzed for the presence of SARS-CoV-2 specific antibodies with a total-antibody bridging ELISA. IgG titers were quantified in samples with a positive test result in the bridging assay. Logistic regression analyses, and linear and logistic mixed model analyses were used to compare COVID-19 related hospitalization rates, proportions of SARS-CoV-2 seropositivity and IgG antibody titers between patients and controls, and between patients stratified for major immunosuppressive drug categories (i.e. biological [b] or conventional synthetic [cs] disease modifying anti-rheumatic drugs [DMARDs]).Findings: In total, 3080 consecutive patients and 1102 healthy controls with comparable age and sex distribution were included for analyses. The incidence of COVID-19 was slightly lower in patients compared to controls (14.7% vs. 16.0% had detectable SARS-CoV-2 antibodies), but patients were more frequently hospitalized compared to controls; 23 of 347 (7%) patients vs. 1 of 134 (0.7%) controls (adjusted OR: 7.33, 95% CI: 0.96 – 55.77, P 0.055). Three (13%) of 23 patients were admitted to the intensive care unit (ICU), and one of these died. Only treatment with B-cell targeting therapy was independently associated with an increased risk of COVID-19 related hospitalization (adjusted OR: 14.62, 95% CI: 2.31 – 92.39, P 0.004). Proportions of SARS-CoV-2 seropositivity in participants with a PCR confirmed COVID-19 diagnosis were similar for patients and controls ( P 0.73), and did not significantly decrease during the first twelve months after infection ( P 0.10). IgG antibody titers were higher in hospitalized patients compared to non-hospitalized patients, and slowly declined with time (rate per month: 0.86, 95% CI: 0.81 – 0.91, P Interpretation: We observed that patients with rheumatic IMIDs, especially those treated with B-cell targeting therapy, were more likely to be hospitalized when infected with SARS-CoV-2, although subsequent ICU admissions and/or death were infrequent. In addition, treatment with cs- or bDMARDs other than B-cell targeting agents is unlikely to have negative effects on the development of long-lasting humoral immunity against SARS-CoV-2.Funding Information: ZonMw and Reade Foundation.Declaration of Interests: None to declare. Ethics Approval Statement: The research protocol was approved by the medical ethical committee of the VU University medical center (registration number 2020.169). All participants gave written informed consent.

Physician-related factors associated with unscheduled revisits to the emergency department and admission to the intensive care unit within 72\xa0h

Investigation of physician-related causes of unscheduled revisits to the emergency department (ED) within 72 h with subsequent admission to the intensive care unit (ICU) is an important parameter of emergency care quality. Between 2012 and 2017, medical records of all adult patients who visited the ED and returned within 72 h with subsequent ICU admission were retrospectively reviewed by three experienced emergency physicians. Study parameters were categorized into “input” (Patient characteristics), “throughput” (Time spent on first ED visit and seniority of emergency physicians, and “output” (Charlson Comorbidity Index). Of the 147 patients reviewed for the causes of ICU admission, 35 were physician-related (23.8%). Eight belonged to more urgent categories, whereas the majority (n = 27) were less urgent. Patients who spent less time on their first ED visits before discharge (< 2 h) were significantly associated with physician-related causes of ICU admission, whereas there was no significant difference in other “input,” “throughput,” and “output” parameters between the “physician-related” and “non-physician-related” groups. Short initial management time was associated with physician-related causes of ICU admission in patients with initial less urgent presentations, highlighting failure of the conventional triage system to identify potentially life-threatening conditions and possibility of misjudgement because of the patients' apparently minor initial presentations.

Risk factors for hospitalization, intensive care, and mortality among patients with asthma and COVID-19

This study describes the presenting characteristics of patients with asthma and COVID-19 in a US health care system, establishing an evidence base for risk evaluation and clinical care for asthma during the COVID-19 pandemic.

Etiology and Prognosis of Pneumonia in Patients with Solid Tumors: A Prospective Cohort of Hospitalized Cases.

Data on the incidence, etiology, and prognosis of non-ventilator-associated pneumonia in hospitalized patients with solid tumors are scarce. We aimed to study the characteristics of non-ventilator-associated pneumonia in hospitalized patients with solid tumors. This was a prospective noninterventional cohort study of pneumonia in patients hospitalized in an oncology ward in a tertiary teaching hospital. Pneumonia was defined according to the American Thoracic Society criteria. Patients were followed for 1 month after diagnosis or until discharge. Survivors were compared with nonsurvivors. A total of 132 episodes of pneumonia were diagnosed over 1 year (9.8% of admissions to the oncology ward). They were health care-related (67.4%) or hospital-acquired pneumonia (31.8%). Lung cancer was the most common malignancy. An etiology was established in 48/132 episodes (36.4%). Knowing the etiology led to changes in antimicrobial therapy in 58.3%. Subsequent intensive care unit admission was required in 10.6% and was linked to inappropriate empirical therapy. Ten-day mortality was 24.2% and was significantly associated with hypoxia (odds ratio [OR], 2.1). Thirty-day mortality was 46.2%. The independent risk factors for 30-day mortality were hypoxia (OR, 3.3), hospital acquisition (OR, 3.1), and a performance status >1 (OR, 2.6). Only 40% of patients who died within 30 days were terminally ill. Pneumonia is a highly prevalent condition in hospitalized patients with solid tumors, even with nonterminal disease. Etiology is diverse, and poor outcome is linked to inappropriate empirical therapy. Efforts to get the empirical therapy right and reach an etiological diagnosis to subsequently de-escalate are warranted. The present study shows that pneumonia is a prevalent infectious complication in patients admitted to oncology wards, with a very high mortality, even in non-terminally ill patients. Etiology is diverse, and etiological diagnosis is reached in fewer than 40% of cases in nonintubated patients. Intensive care unit admission, a marker of poor outcome, is associated with inappropriate empirical therapy. These results suggest that, to improve prognosis, a more precise and appropriate antimicrobial empirical therapy for pneumonia in patients with solid tumors is necessary, together with an effort to reach an etiological diagnosis to facilitate subsequent de-escalation.

Emergency short-stay wards and boarding time in emergency departments: A propensity-score matching study

ObjectivesThis study aimed to validate the effectiveness of an emergency short-stay ward (ESSW) and its impact on clinical outcomes. MethodsThis retrospective observational study was performed at an urban tertiary hospital. An ESSW has been operating in this hospital since September 2017 to reduce emergency department (ED) boarding time and only targets patients indicated for admission to the general ward from the ED. Propensity-score matching was performed for comparison with the control group. The primary outcome was ED boarding time, and the secondary outcomes were subsequent intensive care unit (ICU) admission and 30-day in-hospital mortality. ResultsA total of 7461 patients were enrolled in the study; of them, 1523 patients (20.4%) were admitted to the ESSW. After propensity-score matching, there was no significant difference in the ED boarding time between the ESSW group and the control group (P = 0.237). Subsequent ICU admission was significantly less common in the ESSW group than in the control group (P < 0.001). However, the 30-day in-hospital mortality rate did not differ significantly between the two groups (P = 0.292). When the overall hospital bed occupancy ranged from 90% to 95%, the proportion of hospitalization was the highest in the ESSW group (29%). An interaction effect test using a general linear model confirmed that the ESSW served as an effect modifier with respect to bed occupancy and boarding time (P < 0.001). ConclusionAn ESSW can alleviate prolonged boarding time observed with hospital bed saturation. Moreover, the ESSW is associated with a low rate of subsequent ICU admission.

Are We Out of the Woods Yet? The Aftermath of Resuscitative Thoracotomy

BackgroundAfter traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU. Materials and methodsWe conducted a retrospective review (January 1, 2012–June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome. ResultsOver 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center. ConclusionsAfter resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.

The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge.

Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients. This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization. Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80). Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge. Therapeutic/Care management, level III.

Pre-intensive care unit intubation and subsequent delayed intensive care unit admission is independently associated with increased occurrence of ventilator-associated pneumonia.

Critically ill intubated patients are at risk for ventilator-associated pneumonia. However, intubation may not occur in intensive care unit (ICU) and subsequent ICU admission may be delayed. To evaluate whether intubation >24 h prior ICU admission and delay in ICU admission is associated with ventilator-associated pneumonia (VAP) in non-trauma critically ill patients. Prospective observational study conducted in a medical-surgical ICU of a tertiary hospital. Consecutive patients with >48 h of invasive mechanical ventilation and >72 h hospitalization, were recruited in the study. Pre-ICU intubation and delay in ICU admission, demographical, clinical, microbiological data and ICU interventions were assessed as risk factors for VAP and ICU mortality. 100 patients were included in the study. Pre-ICU intubation and delayed (>24 h) ICU admission (PDA patients) (P=0.014, OR=3.294, confidence interval 1.268-8.557) and SOFA score on ICU admission (P=0.045, OR=1.154, confidence interval 1.003-1.328) were independent risk factors for VAP in ICU care setting. Yet, PDA patients, presented significantly increased incidence of VAP due to MDR bacteria, mainly from Acinetobacter baumannii. Acinetobacter baumannii infection was the only independent risk factor for ICU mortality (P=0.049, OR=3.253, confidence interval 1.006-10.521). SOFA score on ICU admission, presented a fair prognostic accuracy of overall ICU mortality (SOFA≥8.5, AUC=0.850, P<0.001). Pre-ICU intubation and delayed ICU admission was independent risk factor for VAP Acinetobacter baumannii infection and a high SOFA score on ICU admission were predictors of increased ICU mortality.

Extracorporeal membrane oxygenation retrieval factors and survival to intensive care unit discharge.

Audit of extracorporeal membrane oxygenation (ECMO) retrieval service operating in Victoria, Australia, regarding retrieval factors and patient survival to intensive care unit (ICU) discharge. Retrospective cohort analysis of Adult Retrieval Victoria ECMO retrievals with subsequent ICU admission (n = 88) from January 2014 to December 2017. Complications occurring during veno-arterial ECMO transfer have significant association with decreased survival to ICU discharge (P = 0.012). Mortality for veno-arterial ECMO patients was greater than veno-venous ECMO patients. Retrieval ECMO achieves similar survival outcomes to in-house ECMO. The demonstrated relationship of adverse events during retrieval phase to subsequent mortality in ICU highlights the need for optimised case management and retrieval processes.

Respiratory Rate Variability as a Prognostic Factor in Hospitalized Patients Transferred to the Intensive Care Unit.

IntroductionIncreasing mortality rates within the intensive care unit (ICU) is an ever growing problem, ultimately leading to increases in the cost of healthcare expenditures. Currently, there are attempts to use guidelines in the hospital setting to predict overall mortality in critically ill patients. However, a predictor of subsequent ICU admissions remains to be explored. Recent data has shown the importance of monitoring respiratory rate variability (RRV) as a useful predictor of the deterioration of patients. Respiratory rate, in comparison to blood pressure or pulse rate, is deemed as the better determinant in identifying high-risk patients.AimOur study aims to assess the role of RRV monitoring as a potential prognostic marker predictive of ICU admission.ResultsThere was a significant (p = 0.009) increase in RRV between the third and fourth set of respiratory rates prior to ICU admission, such that coefficient of variation percentage (CV%) increased from 0.3% (95% confidence interval (CI): 0.09 - 0.42) to 0.7% (95% CI: 0.04 - 0.9) about 12 hours before admission to the ICU independent from diagnosis.ConclusionUsing elevated RRV as a signal may be a useful prognostic tool in providing early intervention, thus reducing the incidence of subsequent morbidity and mortality in patients that might necessitate an ICU admission.

Time to continuous electroencephalogram in repeated admissions to the pediatric intensive care unit

PurposeDescribe timing from intensive care unit (ICU) admission to initiation of continuous electroencephalogram (cEEG) in repeated ICU admissions. MethodWe performed a retrospective observational study in pediatric patients who underwent repeated ICU admissions with cEEG from 2011 to 2013. The main outcome measure was time from ICU admission to cEEG. ResultsThere were 41 patients (54% males) with at least 2 ICU admissions with cEEG (median (p25-p75) age at first admission: 3.3 (0.3–8.4) years, at second admission: 3.9 (1.1–9.4) years), 7 patients (57% males, 9.9 (2.9–11.5) years) with at least 3 ICU admissions, and 5 patients (60% males, 10.1 (4–10.5) years) with at least 4 ICU admissions. One patient had 21 ICU admissions. The median (p25-p75) time from ICU admission to cEEG was not different during the first and second ICU admissions [10.7 (1.9–22.9) hours versus 13 (0.2–36.7) hours; p=0.908]. Among patients with electrographic seizures on first admission, time to cEEG was not different during the first and second admissions [7.9 (0.5–23.4) hours versus 14.5 (−2 to 44.5) hours; p=0.636]. Among patients with status epilepticus during the first admission, time to cEEG was not different between the first and second admissions [15.3 (9–79) hours versus 40.7 (19.3–42.6) hours; p=0.75]. ConclusionsThe time from ICU admission to the initiation of cEEG did not decrease in second or subsequent ICU admissions, even in patients with seizures or status epilepticus on the first admission.