Medical-surgical Intensive Care Unit Research Articles

102: DOES CASE MIX INDEX TELL THE STORY OF HOW SICK OUR PATIENTS ARE IN AN ICU?

Introduction: CMS uses the case mix index for calculating payments, not for disease severity per se. It is variable based on documentation and coding. APACHE and Acute physiological scoring (APS) are developed to predict disease severity and mortality in ICU. Houston Methodist Baytown (HMB) is considered a complex care hospital for Vizient. The billing and compliance department reviews our ICU documentation periodically. Higher ICU-related DRG services like tracheostomy, ECMO, impella are done. We wanted to evaluate if CMI correlates with mortality rate compared to APACHE and APS in a complex care hospital. Methods: Retrospective study of ICU data at HMB, a 24-bed medical-surgical ICU from Jan 2021 to March 2022. CMI, APACHE, and APS were obtained from ICU (clarity database, EPIC) and VICU dashboards. Descriptive statistics and Pearson correlation was used to evaluate CMI and APACHE, APS in predicting mortality rate. The mortality rate is defined as a percentage of patients with ICU stays who expired during an ICU stay. The mortality index is defined as the observed mortality rate/ expected mortality rate. Results: We had 2758 ICU encounters from January 2021 to March 2022. Mean CMI- 3.426, Mean APACHE -65, Mean APS -54. The average Mortality rate is 8.8%, average mortality index is 0.61. There is a strong positive correlation between APACHE- r=0.914, p=0.029; APS- r= 0.947, p= 0.014 and mortality. CMI also correlated well with mortality r=0.9131, p=0.03. Conclusions: APACHE and APS have strong correlations to predict mortality however CMI also correlated well with the mortality rate for complex care ICU patients. If appropriate documentation and high-risk patient services are provided, then CMI in those hospitals might correlate well with the ICU mortality rate.

Effect of an educational intervention on compliance with care bundle items to prevent ventilator-associated pneumonia

ObjectivesWe aimed to evaluate the effectiveness of our ventilator-associated pneumonia prevention bundle implemented by education of the nursing staff, and to describe the tendency of knowledge retention. Research methodologyA prospective, before-and-after study was performed. The ventilator-associated pneumonia prevention bundle was implemented through a single educational intervention of the nursing staff. The risk of ventilator-associated pneumonia over time was estimated using a Cox proportional cause-specific hazard model. Compliance to preventive measures was assessed at three time-points: before education, at three months and 12 months after education. SettingA 29-bed mixed medical-surgical intensive care unit. Main outcome measuresVentilator-associate pneumonia incidence densities, the risk of ventilator-associated pneumonia, and compliance to preventive measures in the pre-implementation and post-implementation periods. ResultsWe analyzed the data of 251 patients. The incidence density of pneumonia decreased from 29.3/1000 to 15.3/1000 ventilator-days after the implementation of the prevention program. Patients in the post-implementation period had significantly lower risk to develop pneumonia (hazard ratio 0.34, 95 % confidence interval 0.19–0.61, p = 0.001). At 3 months of implementation, a significant improvement was detected to all the individual bundle components. Complete compliance increased from 16.2 % to 62.2 % (p < 0.001). Compliance with bundle components decreased to baseline levels after 12 months of implementation apart from head-of-bed elevation. ConclusionThis study supports existing evidence that educational interventions improve compliance. The gained knowledge was well translated into clinical practice reflected by the decreasing ventilator-associated pneumonia rate. It may be assumed that a refresher educational session within 12 months after implementation is needed.

Retrospective study of risk factors for mortality in critically ill patients with COVID-19

Background: Mortality associated with COVID-19 varies in various reports, with minimal data on the factors associated with in-hospital mortality. Objective: To identify the risk factors for in-hospital death of patients with COVID-19 in an intensive care unit (ICU) in Qatar. Methods: A retrospective observational study of patients confirmed with COVID-19 and admitted to the medical-surgical ICU at The Cuban Hospital was carried out from April 12, 2020, to September 12, 2020. From patients’ electronic medical records, demographic, clinical, laboratory, and radiology data was collected. Results: 275 patients with COVID-19 were admitted to the ICU, and 32 (11.6%) died. 56.1% were men, and the mean age was 52.2 years. According to the univariate analysis, patients with diabetes mellitus with end-organ damage (37.5%), cardiovascular disease (31.3%), dementia (9.4%), kidney disease (28.1%), chronic obstructive pulmonary disease (31.3%), and higher Charlson index had higher mortality. According to the multivariate analysis, an increase of mortality risk by 9% was observed for each additional year of age (Odds ratio [OR] 1.09; 95% confidence interval [CI] 1.04–1.14), patients on mechanical ventilation (OR 27.33; 95% CI 3.21–232.46), and those with adult respiratory distress (OR 15.85; 95% CI 1.45–172.82) and elevated procalcitonin (OR 7.30; 95% CI 1.25–42.58), and the PiO2/FiO2 ratio between 100 and 299 decreased the risk of death by 92% (OR 0.08; 95% CI 0.02–0.39), in comparison to a PiO2/FiO2 ratio less than 100 or greater than 300. Conclusion: The study provides evidence about the risk of mortality among COVID-19 patients with a significant contribution of age, respiratory failure, and co-infections.

Effects of sodium bicarbonate infusion on mortality in medical-surgical ICU patients with metabolic acidosis-A single-center propensity score matched analysis.

Metabolic acidosis is associated with high mortality. Despite theoretical benefits of sodium-bicarbonate (SB), current evidence remains controversial. We investigated SB-related effects on outcomes in ICU patients with metabolic acidosis. Retrospective analysis. Academic medical center. 971 ICU patients with metabolic acidosis defined as arterial pH<7.3 and CO2<45mmHg treated between 2012 and 2016. A propensity score (PS) was estimated using logistic regression. Patients were matched in pairs using the PS. 441 patients were treated with SB 8.4% (SB-group) and n=530 patients were not (control group). Primary outcome was all-cause mortality at ICU-discharge. Average Treatment Effect (ATE), Average Treatment effect in Treated (ATT), and estimated relative survival effects at 20 days were computed. In the full cohort, we observed considerable differences in pH, base excess, additional acidosis-related indices, and ICU mortality (controls 31% vs. SB-group 56%, p<.001) at baseline between the two groups. After PS-matching (n=174 in each group), no significant difference in ICU mortality was observed (controls 32% vs. SB-group 41%; p=.07). Odds ratios (OR) for ATE and ATT showed no association with ICU mortality (OR ATE: 1.08, 95%-CI 0.99-1.17; p=.08; OR ATT 1.09; 95%-CI 0.99-1.2; p=.09). Hazard ratios at 20-days (multivariable HR, matched sample n=348: 1.16, 95%-CI 0.86-1.56, p=.33) showed similar survival in the two study groups. We did not observe effects of SB infusion on all-cause mortality in critically ill patients with metabolic acidosis.

Examination of Impact of After-Hours Admissions on Hospital Resource Use, Patient Outcomes, and Costs.

Nighttime and weekends in hospital and intensive care unit (ICU) contexts are thought to present a greater risk for adverse events than daytime admissions. Although some studies exist comparing admission time with patient outcomes, the results are contradictory. No studies currently exist comparing costs with the time of admission. We investigated the differences in-hospital mortality, ICU length of stay, ICU mortality, and cost between daytime and nighttime admissions. All adult patients (≥18 years of age) admitted to a large academic medical-surgical ICU between 2011 and 2015 were included. Admission cohorts were defined as daytime (8:00-16:59) or nighttime (17:00-07:59). Student's t-tests and chi-squared tests were used to test for associations between days spent in the ICU, days on mechanical ventilation, comorbidities, diagnoses, and cohort membership. Regression analysis was used to test for associations between patient and hospitalization characteristics and in-hospital mortality and total ICU costs. The majority of admissions occurred during nighttime hours (69.5%) with no difference in the overall Elixhauser comorbidity score between groups (p=0.22). Overall ICU length of stay was 7.96 days for daytime admissions compared to 7.07 days (p=0.001) for patients admitted during nighttime hours. Overall mortality was significantly higher in daytime admissions (22.5% vs 20.6, p=0.012); however, ICU mortality was not different. The average MODS was 2.9 with those admitted during the daytime having a significantly higher MODS (3.0, p=0.046). Total ICU cost was significantly higher for daytime admissions (p=0.003). Adjusted ICU mortality was similar in both groups despite an increased rate of adverse events for nighttime admissions. Daytime admissions were associated with increased cost. There was no difference in all hospital total cost or all hospital direct cost between groups. These findings are likely due to the higher severity of illness in daytime admissions. Daytime admissions were associated with a higher severity of illness, mortality rate, and ICU cost. To further account for the effect of staffing differences during off-hours, it may be beneficial to compare weekday and weeknight admission times with associated mortality rates.

Patient and family engagement in patient care and research in Canadian intensive care units: a national survey.

While patient and family engagement may improve clinical care and research, current practices for engagement in Canadian intensive care units (ICUs) are unknown. We developed and administered a cross-sectional questionnaire to ICU leaders of current engagement practices, facilitators, and barriers to engagement, and whether engagement was a priority, using to an ordinal Likert scale from 1 to 10. The response rate was 53.4% (124/232). Respondents were from 11 provinces and territories, mainly from medical surgical ICUs (76%) and community hospitals (70%). Engagement in patient care included bedside care (84%) and bedside rounds (66%), presence during procedures/crises (65%), and survey completion (77%). Research engagement included ethics committees (36%), protocol review (31%), and knowledge translation (30%). Facilitators of engagement in patient care included family meetings (87%), open visitation policies (81%), and engagement as an institutional priority (74%). Support from departmental (43%) and hospital (33%) leadership was facilitator of research engagement. Time was the main barrier to engagement in any capacity. Engagement was a higher priority in patient care vs research (median [interquartile range], 8 [7-9] vs 3 [1-7]; P < 0.001) and in pediatric vs adult ICUs (10 [9-10] vs 8 [7-9]; P = 0.003). Research engagement was significantly higher in academic vs other ICUs (7 [5-8] vs 2 [1-4]; P < 0.001), and pediatric vs adult ICUs (7 [5-8] vs 3 [1-6]; P = 0.01). Organizational strategies and institutional support were key facilitators of engagement. Engagement in patient care was a higher priority than engagement in research.

Compliance of non-pharmacological preventive practice of venous thromboembolism among Jordanian nurses.

Many practices, such as non-pharmacological preventive practices, have demonstrated significant improvement and reduced the venous thromboembolism incidence. This study aims at investigating the compliance with non-pharmacological preventive practice of venous thromboembolism guidelines among Jordanian intensive care and medical and surgical nurses. Descriptive and cross-sectional with the non-participant observational design was used. This study recruited 271 registered nurses in adult medical-surgical units and intensive care units of 12 different government hospitals in Jordan's middle and north regions. The observational checklist included 10 preventive practices based on the non-pharmacological preventive of venous thromboembolism guidelines. In the observational checklist, the highest score was 20, and the lowest was 0. If the nurse received equal to or higher than (>14) score were classified as sufficient compliance, while insufficient compliance was (≤14) score. The observations period started from September 2019 until March 2020. The participants' overall mean venous thromboembolism compliance score was insufficient compliance (10.6 ± 1.6). The majority of nurses were classified as insufficient compliance 67%. "Doing foot exercise and early ambulation 2 times per day 50.3%" and "checked the integrity of the patient's skin at regular intervals 50.0%" were the highest practices done rightly and completely by half of the participants. The participants who had a bachelor of nursing degree, staff nurse, and works in the intensive care unit, are less experienced and have no previous venous thromboembolism education reported low venous thromboembolism compliance. This study presents expanded compliance regarding venous thromboembolism preventive practices among Jordanian intensive care and medical & surgical nurses, so the policymakers need to develop an initiative to improve nurses' compliance.

LBSUN214 Accuracy Of A Continuous Glucose Monitor In The Intensive Care Unit

Abstract Studies have shown that hyper/hypoglycemia and glycemic variation are associated with adverse outcomes in critically ill patients. Currently, frequent blood point-of-care (POC) glucose measurements from an arterial or capillary sample is the only technology available to minimize glycemic excursions in the ICU. Continuous glucose monitoring (CGM) is becoming the standard of care for outpatient diabetes care and has shown improved glycemic control in the non-ICU inpatient setting. The Dexcom G6 sensor (G6) is the first CGM device approved by Health Canada for outpatient diabetes management without the need for calibration, but it has not yet been approved for inpatient use. We collected data from 23 adults who were on an insulin infusion in a medical-surgical ICU in Vancouver, British Columbia to evaluate the accuracy of uncalibrated CGM in the ICU. A blinded G6 was attached to the patient's arm and collected glucose measurements every five minutes without calibration. Nursing staff continued POC arterial glucose measurements using the AccuChek Inform II machine per standard of care. Excluding four outliers (with mean absolute relative difference (MARD) ≥ 25%), the overall MARD was 13.24% (SE 0.43) over 649 matched CGM and arterial glucose values. A Clarke Error Grid demonstrated 99.1% of CGM measurements within zones A and B. The MARD using three-point rolling averages of CGM measurements in five-minute intervals was 13.49% (SE 0.68). There were 573 matched pairs between glucose ranges of 3.9-13.9 mmol/L with two pairs &amp;lt;3.9 and 74 pairs &amp;gt;13.9 mmol/L. Eleven patients had renal replacement therapy and twelve had vasopressor use. There was no significant difference in MARD with renal replacement or across glycemic ranges ≥3.9. The MARD for patients with vasopressors was lower than for patients without (13% vs 13.55%, p&amp;lt;0. 01), a finding of doubtful clinical relevance. There is no expert agreement yet about the acceptable accuracy for CGM use in hospital. Our overall MARD meets the 2013 Critical Care expert consensus recommendations for MARD &amp;lt;14%. The FDA guidance on standard of accuracy for conventional POC glucometers require 98% of values within 15% for BG ≥ 75mg/dL. Our data showed 65.18% of values were within 15%. Previous studies using CGM in the ICU, even those using G6, all used calibration. The majority were non-blinded, and none met FDA criteria for inpatient use. Our study is the first uncalibrated and blinded study that was able to demonstrate acceptable accuracy in a large sample size. Since CGM accuracy may be affected by various factors, our comprehensive data can potentially identify specific interferences and quantify a calibration or correction criteria to improve CGM accuracy in critically ill patients. Overall, our results show that CGM shows strong potential to be an accurate, resource-efficient, and intuitive alternative to POC glucose monitoring to meet glycemic targets in the ICU. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Effects of sodium bicarbonate infusion on mortality in medical–surgical ICU patients with metabolic acidosis—A single-center propensity score matched analysis

ObjectiveMetabolic acidosis is associated with high mortality. Despite theoretical benefits of sodium-bicarbonate (SB), current evidence remains controversial. We investigated SB-related effects on outcomes in ICU patients with metabolic acidosis. DesignRetrospective analysis. SettingAcademic medical center. Patients or participants971 ICU patients with metabolic acidosis defined as arterial pH<7.3 and CO2<45mmHg treated between 2012 and 2016. A propensity score (PS) was estimated using logistic regression. Patients were matched in pairs using the PS. Interventions441 patients were treated with SB 8.4% (SB-group) and n=530 patients were not (control group). Main variables of interestPrimary outcome was all-cause mortality at ICU-discharge. Average Treatment Effect (ATE), Average Treatment effect in Treated (ATT), and estimated relative survival effects at 20 days were computed. ResultsIn the full cohort, we observed considerable differences in pH, base excess, additional acidosis-related indices, and ICU mortality (controls 31% vs. SB-group 56%, p<.001) at baseline between the two groups. After PS-matching (n=174 in each group), no significant difference in ICU mortality was observed (controls 32% vs. SB-group 41%; p=.07). Odds ratios (OR) for ATE and ATT showed no association with ICU mortality (OR ATE: 1.08, 95%-CI 0.99–1.17; p=.08; OR ATT 1.09; 95%-CI 0.99–1.2; p=.09). Hazard ratios at 20-days (multivariable HR, matched sample n=348: 1.16, 95%-CI 0.86–1.56, p=.33) showed similar survival in the two study groups. ConclusionsWe did not observe effects of SB infusion on all-cause mortality in critically ill patients with metabolic acidosis.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

VASOPRESSOR-RESISTANT HYPOTENSION, COMBINATION VASOPRESSOR THERAPY, AND SHOCK PHENOTYPES IN CRITICALLY ILL ADULTS WITH VASODILATORY SHOCK.

ABSTRACTObjective: To examine the risk factors, resource utilization, and 1-year mortality associated with vasopressor-resistant hypotension (VRH) compared with vasopressor-sensitive hypotension (VSH) among critically ill adults with vasodilatory shock. We also examined whether combination vasopressor therapy and patient phenotype were associated with mortality. Design: Retrospective cohort study. Setting: Eight medical-surgical intensive care units at the University of Pittsburgh Medical Center, Pittsburgh, PA. Patients: Critically ill patients with vasodilatory shock admitted between July 2000 and October 2008. Interventions: None. Measurements and Main Results: Vasopressor-resistant hypotension was defined as those requiring greater than 0.2 μg/kg per minute of norepinephrine equivalent dose of vasopressor consecutively for more than 6 h, and VSH was defined as patients requiring ≤0.2 μg/kg per minute to maintain MAP between 55 and 70 mm Hg after adequate fluid resuscitation. Of 5,313 patients with vasodilatory shock, 1,291 patients (24.3%) developed VRH. Compared with VSH, VRH was associated with increased risk of acute kidney injury (72.7% vs. 65.0%; P < 0.001), use of kidney replacement therapy (26.0% vs. 11.0%; P < 0.001), longer median (interquartile range [IQR]) intensive care unit length of stay (10 [IQR, 4.0–20.0] vs. 6 [IQR, 3.0–13.0] days; P < 0.001), and increased 1-year mortality (64.7% vs. 34.8%; P < 0.001). Vasopressor-resistant hypotension was associated with increased odds of risk-adjusted mortality (adjusted odds ratio [aOR], 2.93; 95% confidence interval [CI], 2.52–3.40; P < 0.001). When compared with monotherapy, combination vasopressor therapy with two (aOR, 0.91; 95% CI, 0.78–1.06) and three or more vasopressors was not associated with lower mortality (aOR, 0.93; 95% CI, 0.68–1.27). Using a finite mixture model, we identified four unique phenotypes of patient clusters that differed with respect to demographics, severity of illness, processes of care, vasopressor use, and outcomes. Conclusions: Among critically ill patients with vasodilatory shock, VRH compared with VSH is associated with increased resource utilization and long-term risk of death. However, combination vasopressor therapy was not associated with lower risk of death. We identified four unique phenotypes of patient clusters that require further validation.

Family participation in the care of the critical patient: An exploratory study

ObjectivesTo determine the level of readiness of the healthcare team regarding family participation in the care of the critically ill adult and their relationship with the individual characteristics of the participants in a medical-surgical intensive care unit (ICU) in Santiago de Chile. MethodA cross-sectional correlational study using a quantitative method and including a focus group to explore the perception of healthcare staff of family participation in the care of the critically ill patient. ResultsThe level of readiness of the healthcare team for family participation in the care of the critically ill patient is medium, at 13.81 out of a total 20. The greater the readiness, the lower the age (r = −0.215; P = 0.019), the higher the rating of previous experience working with families (r = 0.304; P = 0.006), and the higher the perception of being comfortable with different activities in the care of the critical patient (r = 0.495: P < 0.001). The participants also state that the work environment of the unit, the patient's condition, the relatives’ characteristics, personal judgement, and the preparedness of relatives affect their readiness. ConclusionsThe results contribute towards determining the healthcare team's level of readiness in a setting where the subject of the study has not been implemented. The readiness of the healthcare team is medium, and is related to individual characteristics of the healthcare staff, and to organizational and family aspects. Therefore, strategies are required to address these aspects that might increase readiness.

The Glycemic Ratio Is Strongly and Independently Associated With Mortality in the Critically Ill.

Interventional studies investigating blood glucose (BG) management in intensive care units (ICU) have been inconclusive. New insights are needed. We assessed the ability of a new metric, the Glycemic Ratio (GR), to determine the relationship of ICU glucose control relative to preadmission glycemia and mortality. Retrospective cohort investigation (n = 4790) in an adult medical-surgical ICU included patients with minimum four BGs, hemoglobin (Hgb), and hemoglobin A1c (HbA1c). The GR is the quotient of mean ICU BGs (mBG) and estimated preadmission BG, derived from HbA1c. Mortality displayed a J-shaped curve with GR (nadir GR 0.9), independent of background glycemia, consistent for HbA1c <6.5% vs >6.5%, and Hgb >10 g/dL vs <10 g/dL and medical versus surgical. An optimal range of GR 0.80 to 0.99 was associated with decreased mortality compared with GR above and below this range. The mBG displayed a linear relationship with mortality at lower HbA1c but diminished for HbA1c >6.5%, and dependent on preadmission glycemia. In adjusted analysis, GR remained associated with mortality (odds ratio = 2.61, 95% confidence interval = 1.48-4.62, P = .0012), but mBG did not (1.004, 1.000-1.009, .059). A single value on admission was not independently associated with mortality. The GR provided new insight into malglycemia that was not apparent using mBG, or an admission value. Mortality was associated with acute change from preadmission glycemia (GR). Further assessment of the impact of GR deviations from the nadir in mortality at GR 0.80 to 0.99, as both relative hypo- and hyperglycemia, and as duration of exposure and intensity, may further define the multifaceted nature of malglycemia.

The Role of Organizational Support in Work Engagement Among Nurses Working in Intensive Care Units

Introduction: The challenges and difficulties of working in intensive care units put pressure on healthcare professionals, especially nurses. To support nurses working in intensive care units (ICUs), developing supportive climates in organizations may drive nurses towards increasing work engagement levels and other related factors. Objective: This study aimed to determine the relationship between organizational support and the work engagement of nurses working in ICUs. Materials and Methods: This correlational cross-sectional study was conducted on 140 nurses working in two governmental hospitals in Amman City, Jordan, from January to August 2021. The participants were selected with a simple random sampling method, and study data were collected using a 3-part questionnaire: demographics, the survey of perceived organizational support scale with 8 items, and the Utrecht work engagement scale with 9 items. Descriptive statistics, the independent t test, the Spearman correlation test, and hierarchal multiple linear regression analysis were performed to determine the contribution of perceived organizational support on nurses' work engagement. The significance level for all tests was set to be less than 0.05. Results: About 53.6% of participants were male, 55% worked in medical-surgical intensive care units, and 45% were in cardiac care units. The results showed that the mean ± SD scores of perceived organizational support and work engagement were 29.53 ± 6.71 and 3.71 ± 0.88, respectively. Also, results showed no significant differences in perceived organizational support and work engagement based on nurses' socio-demographics or work-related factors. Finally, there was a significant positive weak correlation between perceived organizational support and work engagement (r= 0.23, P=0.002). The linear regression model showed that perceived organizational support could predict work engagement (R2 = 0.039). Conclusions: Perceived organizational support among nurses working in ICUs is one of the important factors in increasing work engagement. Findings have several implications for nurses in different settings. Jordanian health policymakers must take action to improve nurses' perception of organizational support and consequently increase nurses' work engagement.

One-hour plasma glucose level after a 75 g oral glucose load and its relationship to gastric emptying in survivors of critical illness and stress hyperglycaemia

Objective: A 1-hour plasma glucose level ≥ 8.6 mmol/L in a 75 g oral glucose tolerance test has been strongly associated with increased morbidity and mortality in outpatients without diabetes. Our primary aim was to evaluate the 1-hour plasma glucose level in a 75 g glucose tolerance test in survivors of critical illness with stress hyperglycaemia at 3 months after intensive care unit (ICU) discharge, with the secondary aims to evaluate the 2-hour plasma glucose level, glycated haemoglobin (HbA1c), and gastric emptying. Design:Post hoc analysis of a single-centre, prospective cohort study. Setting: Single-centre, tertiary referral, mixed medical-surgical ICU. Participants: Consecutively admitted patients aged ≥ 18 years who developed stress hyperglycaemia and survived to hospital discharge were eligible. Interventions: Participants returned at 3 months after ICU discharge and underwent a 75 g oral glucose tolerance test. Main outcome measures: One- and 2-hour post load plasma glucose level, HbA1c, and assessment of gastric emptying via an isotope breath test. Results: Thirty-five patients (12 females; mean age, 58.5 years [SD, 10.5]; mean HbA1c, 37.4 mmol/mol [SD, 7.0]) attended the followup. In 32/35 patients (91%) the 1-hour post load plasma glucose level was ≥ 8.6 mmol/L. There was a positive correlation between the plasma glucose level at 1 hour (r2 = 0.21; P = 0.006), but no correlation between the 2-hour glucose level (r2 = 0.006; P = 0.63) and gastric emptying. Conclusion: Glucose intolerance, when defined as 1-hour glucose level ≥ 8.6 mmol/L following a 75 g oral glucose load, persists at 3 months in most survivors of stress hyperglycaemia and is dependent on the rate of gastric emptying. Longitudinal studies to characterise mechanisms underlying dysglycaemia and progression to diabetes in individuals with stress hyperglycaemia are indicated.

Impact of Family Presence on Delirium in Critically Ill Patients: A Retrospective Cohort Study.

OBJECTIVE:To assess the effect of family presence on the prevalence and duration of delirium in adults admitted to an ICU.DESIGN:Retrospective cohort study.SETTING:Medical-surgical ICUs in Alberta, AB, Canada.PATIENTS:A population of 25,537 unique patients admitted at least once to an Alberta ICU.METHODS:We obtained electronic health records of consecutive adults (≥ 18 yr) admitted to one of 14 medical-surgical ICU in Alberta, Canada, from January 1, 2014, to December 30, 2018. Family presence was quantified using a validated algorithm and categorized as: 1) physical presence in ICU, 2) telephone call only, and 3) no presence (reference group). Delirium was measured using the Intensive Care Delirium Screening Checklist (ICDSC) and defined as an ICDSC greater than or equal to 4. Multivariable mixed-effects logistic and linear regression were used to evaluate the association between family presence and prevalence (binary) and duration (d) of delirium, respectively.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:The association between family presence and delirium prevalence differed according to admission type and admission Glasgow Coma Scale (GCS). Among medical and emergency surgical patients irrespective of admission GCS, physical presence of family was not significantly associated with the prevalence of delirium. In elective surgical patients, physical presence of family was associated with decreased prevalence of delirium in patients with intact Glasgow Coma Scale (GCS = 15; adjusted odds ratio, 0.60; 95% CI, 0.39–0.97; p = 0.02). Physical presence of family (adjusted mean difference [AMD] –1.87 d; 95% CI, –2.01 to –1.81; p < 0.001) and telephone calls (AMD –1.41 d; 95% CI, –1.52 to –1.31; p < 0.001) were associated with decreased duration of delirium in all patients.CONCLUSIONS:The effects of family presence on delirium are complex and dependent on type of visitation, reason for ICU admission, and brain function on ICU admission.

Demographic analysis of profile of neurosurgical patients at tertiary care medical school in Eastern India

Background: Since becoming a distinct field of medicine, neurosurgery now admits some of the most frequent patients to the intensive care unit. The study's goal was to examine the characteristics of neurosurgical patients admitted to a level III mixed, medical-surgical intensive care unit in a tertiary hospital in Eastern India in order to determine the reasons for these patients' admissions, as well as their outcomes in terms of length of stay in the unit and mortality. Methods: An investigation was carried out in IMS and SUM Hospital, Bhubaneshwar following ethical approval from the institute's Institutional Review Committee. The study covered all patients with neurosurgical issues admitted to the ICU for the 12-month period from January 2021 to December 2021. Results: During the one-year study period, a total of 659 neurosurgical patients were admitted in the ICU. Among them 445 (67.53%) were males and 214 (32.47%) were females. Age wise distribution showed patients aged between 18 and 60 years to be the most common at 476 (72.23%). Sixty (9.10%) patients aged below 18 years, while 123 (18.66%) were aged more than 60 years. It showed that maximum patients had trauma 150(22.76%).

Mental health-related quality of life is related to delirium in intensive care patients.

Delirium during intensive care unit (ICU) stay may be related to premorbid mental illness. In addition, delirium during ICU stay may also negatively affect long-term health-related quality of life. The aim of our study was to investigate if delirium in the ICU is related to premorbid mental quality of life and affects long-term mental quality of life after ICU stay. We performed a prospective cohort study in 1021 patients admitted for longer than 48h in a medical-surgical ICU. We evaluated mental and physical quality of life using the Short-form-12 before ICU admission, at hospital discharge, and 3, 6 and 12months after hospital discharge. Mixed model and logistic regression models were used to analyze the data. Patients who experienced a delirium during ICU stay reported a worse pre-admission mental quality of life than those without delirium (p < 0.001). Furthermore, patients who suffered from delirium during their ICU stay exhibited a significant decrease in mental quality of life over time relative to patients without delirium (p = 0.035). In this large follow-up study, we demonstrated that ICU survivors who experienced a delirium during ICU stay reported a significantly worse pre-admission mental health-related quality of life and a significant decrease in mental health-related quality of life in the year after hospital discharge compared with patients without delirium.

Data-driven methodology to predict the ICU length of stay: A multicentre study of 99,492 admissions in 109 Brazilian units

PurposeThe length of stay (LoS) is one of the most used metrics for resource use in Intensive Care Units (ICU). We propose a structured data-driven methodology to predict the ICU length of stay and the risk of prolonged stay, and its application in a large multicentre Brazilian ICU database. MethodsDemographic data, comorbidities, complications, laboratory data, and primary and secondary diagnosis were prospectively collected and retrospectively analysed by a data-driven methodology, which includes eight different machine learning models and a stacking model. The study setting included 109 mixed-type ICUs from 38 Brazilian hospitals and the external validation was performed by 93 medical-surgical ICUs of 55 hospitals in Brazil. ResultsA cohort of 99,492 adult ICU admissions were included from the 1st of January to the 31st of December 2019. The stacking model combining Random Forests and Linear Regression presented the best results to predict ICU length of stay (RMSE = 3.82; MAE = 2.52; R² = 0.36). The prediction model for the risk of long stay were accurate to early identify prolonged stay patients (Brier Score = 0.04, AUC = 0.87, PPV = 0.83, NPV = 0.95). ConclusionThe data-driven methodology to predict ICU length of stay and the risk of long-stay proved accurate in a large multicentre cohort of general ICU patients. The proposed models are helpful to predict the individual length of stay and to early identify patients with high risk of prolonged stay.

A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care.

Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward. Multiple baseline trial with randomized and staggered implementation. Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city. Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019. A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system. We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process. Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.