Tertiary Intensive Care Unit Research Articles

Antimicrobial drug utilization pattern in a tertiary level intensive care unit in Northern India: Antimicrobial Stewardship Programme need of the hour

Background: Antimicrobial drugs are the most frequently prescribed drugs in hospital settings with intensive care unit (ICU) patients showing the highest consumption of these drugs. Antimicrobial overuse and misuse is attributed to antimicrobial resistance (AMR). AMR in coming years will emerge as a global pandemic, maiming the modern health-care system. High consumption of antimicrobial drugs is one of leading factors contributing to AMR. Aims and Objectives: This study aimed at evaluating the prescription pattern of antimicrobial drugs in ICU and estimates the burden of inappropriate antimicrobial drug utilization in ICU settings of a tertiary level teaching hospital. Materials and Methods: The current study was conducted on 100 patients over a period of 6 months, admitted in surgical ICU (SICU), and neuro SICU (NICU) of a tertiary level hospital in Jammu and Kashmir, India. Study patients were identified through daily review of pharmacy records and antimicrobial drugs prescribed for the initial 5 days of ICU admission were documented in a well-designed questionnaire consisting all the necessary information regarding antibiotic therapy. Results: Out of the 100 enrolled study subjects, 98% received an empiric therapy. Majority of the patients were given a combination antimicrobial therapy during the initial 5 days of ICU admission. The most common antibiotic prescribed as monotherapy was ceftriaxone during the initial 2 days of ICU stay followed by piperacillin-tazobactam and meropenem in the next 3 days. Amikacin was the most frequently prescribed antibiotic in combination therapy during first 2 days followed by vancomycin in the consecutive days. A total of 27 antimicrobial drugs belonging to 15 classes were prescribed to the study participants during the initial 5 days of ICU admission. Conclusion: The study reports a very high consumption of antimicrobial drugs in ICUs with maximum of antimicrobial therapies prescribed empirically. A robust action plan, consisting of proper protocol for prescribing empiric antimicrobials, regular monitoring of antibiotic consumption in ICUs with a system of prospective audit, and feedback and timely interventions are a keystone of good antibiotic stewardship and should be the focus in ICU and NICU.

The relationship between nursing skill mix and severity of illness of patients admitted in Australian and New Zealand intensive care units

BackgroundCritically ill patients in the intensive care environment require an appropriate nursing workforce to improve quality of care and patient outcomes. However, limited information exists as to the relationship between severity of illness and nursing skill mix in the intensive care. ObjectiveThe aim of this study was to describe the variation in nursing skill mix across different hospital types and to determine if this was associated with severity of illness of critically ill patients admitted to adult intensive care units (ICUs) in Australia and New Zealand. Design & SettingA retrospective cohort study using the Australia and New Zealand Intensive Care Society Adult Patient Database (to provide information on patient demographics, severity of illness, and outcome) and the Critical Care Resources Registry (to provide information on annual nursing staffing levels and hospital type) from July 2014 to June 2020. Four hospital types (metropolitan, private, rural/regional, and tertiary) and three patient groups (elective surgical, emergency surgical, and medical) were examined. Main outcome measureThe main outcome measure was the proportion of critical care specialist registered nurses (RNs) expressed as a percentage of the full-time equivalent (FTE) of total RNs working within each ICU each year, as reported annually to the Critical Care Resources Registry. ResultsData were examined for 184 ICUs in Australia and New Zealand. During the 6-year study period, 770 747 patients were admitted to these ICUs. Across Australia and New Zealand, the median percentage of registered nursing FTE with a critical care qualification for each ICU (n = 184) was 59.1% (interquartile range [IQR] = 48.9–71.6). The percentage FTE of critical care specialist RNs was highest in private [63.7% (IQR = 52.6–78.2)] and tertiary ICUs [58.1% (IQR = 51.2–70.2)], followed by metropolitan ICUs [56.0% (IQR = 44.5–68.9)] with the lowest in rural/regional hospitals [55.9% (IQR = 44.9–70.0)]. In ICUs with higher percentage FTE of critical care specialist RNs, patients had higher severity of illness, most notably in tertiary and private ICUs. This relationship was persistent across all hospital types when examining subgroups of emergency surgical and medical patients and in multivariable analysis after adjusting for the type of hospital and relative percentage of each diagnostic group. ConclusionsIn Australian and New Zealand ICUs, the highest acuity patients are cared for by nursing teams with the highest percentage FTE of critical care specialist RNs. The Australian and New Zealand healthcare system has a critical care nursing workforce which scales to meet the acuity of ICU patients across Australia and New Zealand.

The effect of duration of antimicrobial treatment for bacteremia in critically ill patients on in-hospital mortality – Retrospective double center analysis

PurposeExcessive duration of antibiotic treatment is a major factor for inappropriate antibiotic consumption. Although in some instances shorter antibiotic courses are as efficient as longer ones, no specific recommendations as to the duration of antimicrobial treatment for bloodstream infections currently exist. In the present study, we investigated the effect of antibiotic treatment duration on in-hospital mortality using retrospective data from two cohorts that included patients with bacteremia at two Swiss tertiary Intensive Care Units (ICUs). Materials and methodsOverall 8227 consecutive patients requiring ICU admission were screened for bacteremia between 01/2012–12/2013 in Lausanne and between 07/2016–05/2017 in Bern. Patients with an infection known to require prolonged treatment or having single positive blood culture with common contaminant pathogens were excluded. The primary outcome of interest was the time from start of antimicrobial treatment to in-hospital death or hospital discharge, whichever comes first. The predictor of interest was adequate antimicrobial treatment duration, further divided into shorter (≤10 days) and longer (>10 days) durations. A time-dependent Cox model and a cloning approach were used to address immortality bias. The secondary outcomes were the median duration of antimicrobial treatment for patients with bacteremia overall and stratified by underlying infectious syndrome and pathogens in the case of secondary bacteremia. ResultsOut of the 707 patients with positive blood cultures, 382 were included into the primary analysis. Median duration of antibiotic therapy was 14 days (IQR, 7–20). Most bacteremia (84%) were monomicrobial; 18% of all episodes were primary bacteremia. Respiratory (28%), intra-abdominal (23%) and catheter infections (17%) were the most common sources of secondary bacteremia. Using methods to mitigate the risk of confounding associated with antibiotic treatment durations, shorter versus longer treatment groups showed no differences in in-hospital survival (time-dependent Cox-model: HR 1.5, 95% CI (0.8, 2.7), p = 0.20; Cloning approach: HR 1.0, 95% CI (0.7,1.5) p = 0.83). Sensitivity analyses showed that the interpretation did not change when using a 7 days cut-off. ConclusionsIn this restrospective study, we found no evidence for a survival benefit of longer (>10 days) versus shorter treatment course in ICU patients with bacteremia. Trial registrationThe study was retrospectively registered on clinicatrials.gov (NCT05236283), 11 February 2022. The respective cantonal ethics commission (KEK Bern # 2021–02302) has approved the study.

Are bacterial coinfections really rare in COVID-19 intensive care units?

ObjectivesThere are limited data about nosocomial coinfections of COVID-19 cases monitored in the intensive care unit. This study aims to investigate coinfections in COVID-19 patients followed in an intensive care unit of a university hospital.MethodsThis study analyzed retrospectively the data of coinfections of 351 COVID-19 patients in the period 28.02.2020–15.01.2021 in a tertiary care intensive care unit in a university hospital.ResultsBacterial coinfections were present in 216 of the 351 cases. One hundred and thirty of these cases were evaluated as nosocomial infections. On the third day the Sequential Organ Failure Assessment Score, usage of invasive mechanical ventilation and presence of septic shock were significantly higher in the coinfected group. The neutrophil/lymphocyte ratio, polymorphonuclear leukocyte count, procalcitonin, ferritin, and blood urea nitrogen values were significantly higher in the coinfection group. White blood cells (WBC) (OR: 1.075, 95% CI 1.032–1.121, p = 0.001) and ICU hospitalization day (OR: 1.114, 95% CI 1.063–1.167, p < 0.001) were found to be independent risk factors for coinfection in the multivariate logistic regression analysis. The rates of hospitalization day on the day of arrival, the 21st day, as well as total mortality (p = 0.004), were significantly higher in the coinfected group.ConclusionBacterial coinfections of COVID-19 patients in the intensive care unit remain a problem. Identifying the infectious agent, classifying colonizations and infections, and using the proper treatment of antibiotics are of great importance in the case management of COVID-19 patients in the intensive care unit.

Long-term respiratory follow-up of ICU hospitalized COVID-19 patients: Prospective cohort study.

Coronavirus disease (COVID-19) survivors exhibit multisystemic alterations after hospitalization. Little is known about long-term imaging and pulmonary function of hospitalized patients intensive care unit (ICU) who survive COVID-19. We aimed to investigate long-term consequences of COVID-19 on the respiratory system of patients discharged from hospital ICU and identify risk factors associated with chest computed tomography (CT) lesion severity. A prospective cohort study of COVID-19 patients admitted to a tertiary hospital ICU in Brazil (March-August/2020), and followed-up six-twelve months after hospital admission. Initial assessment included: modified Medical Research Council dyspnea scale, SpO2 evaluation, forced vital capacity, and chest X-Ray. Patients with alterations in at least one of these examinations were eligible for CT and pulmonary function tests (PFTs) approximately 16 months after hospital admission. Primary outcome: CT lesion severity (fibrotic-like or non-fibrotic-like). Baseline clinical variables were used to build a machine learning model (ML) to predict the severity of CT lesion. In total, 326 patients (72%) were eligible for CT and PFTs. COVID-19 CT lesions were identified in 81.8% of patients, and half of them showed mild restrictive lung impairment and impaired lung diffusion capacity. Patients with COVID-19 CT findings were stratified into two categories of lesion severity: non-fibrotic-like (50.8%-ground-glass opacities/reticulations) and fibrotic-like (49.2%-traction bronchiectasis/architectural distortion). No association between CT feature severity and altered lung diffusion or functional restrictive/obstructive patterns was found. The ML detected that male sex, ICU and invasive mechanic ventilation (IMV) period, tracheostomy and vasoactive drug need during hospitalization were predictors of CT lesion severity(sensitivity,0.78±0.02;specificity,0.79±0.01;F1-score,0.78±0.02;positive predictive rate,0.78±0.02; accuracy,0.78±0.02; and area under the curve,0.83±0.01). ICU hospitalization due to COVID-19 led to respiratory system alterations six-twelve months after hospital admission. Male sex and critical disease acute phase, characterized by a longer ICU and IMV period, and need for tracheostomy and vasoactive drugs, were risk factors for severe CT lesions six-twelve months after hospital admission.

Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention

BackgroundCritically ill patients receive frequent routine and recurring blood tests, some of which are unnecessary.AimTo reduce unnecessary routine phlebotomy in a 30-bed tertiary medical-surgical intensive care unit (ICU) in Toronto,...

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study

Background The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed. Objective To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE. Design & Setting We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient. Results A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944–0.988], p 0.003). Conclusion An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

Evaluation of nosocomial infections in a tertiary intensive care unit

Evaluation of nosocomial infections in a tertiary intensive care unit

Identifying Opportunities for Antimicrobial Stewardship in a Tertiary Intensive Care Unit: A Qualitative Study

Background: Antimicrobial stewardship (AMS) encompasses numerous interventions that seek to improve antimicrobial usage, as inappropriate use of antimicrobials may result in the promotion of antimicrobial resistance, patient harm, and increased costs. AMS is of particular interest in intensive care units (ICUs) where antimicrobial use is extensive. Few qualitative studies have sought to identify the perceived attitudes and beliefs of intensive care clinicians around AMS. Objectives: To understand ICU nursing and physician priorities and preferences around AMS and possible AMS interventions for implementation in the ICU. Methods: Using consecutive sampling, semi-structured one-to-one interviews were conducted with ICU nursing and physician staff at a tertiary hospital in BC, Canada. Results: Nine participants (seven nurses and two physicians) were interviewed, and themes were identified and categorized as: opportunities to improve AMS in the ICU, barriers to AMS in the ICU, and possible future AMS interventions for implementation in the ICU. Opportunities identified included: clinician activities (improved communication, de-escalation, ICU nurse assessment) and support (infectious disease and antibiotic experts, AMS presence). Barriers identified included: knowledge gaps (infectious disease and antibiotic knowledge, AMS awareness), AMS and ICU integration (nursing role in AMS, AMS efficacy in ICU), and environment (competing priorities, critical care context). Interventions identified included: organisational (EMR modifications, checklists, algorithms), learning (infectious disease and antimicrobial education, audit, and feedback), and nursing intervention (antibiotic review, prompting reassessment).

Delirium severity and outcomes of critically ill COVID-19 patients.

To investigate the impact of delirium severity in critically ill COVID-19 patients and its association with outcomes. This prospective cohort study was performed in two tertiary intensive care units in Rio de Janeiro, Brazil. COVID-19 patients were evaluated daily during the first 7 days of intensive care unit stay using the Richmond Agitation Sedation Scale, Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Confusion Method Assessment for Intensive Care Unit-7 (CAM-ICU-7). Delirium severity was correlated with outcomes and one-year mortality. Among the 277 COVID-19 patients included, delirium occurred in 101 (36.5%) during the first 7 days of intensive care unit stay, and it was associated with a higher length of intensive care unit stay in days (IQR 13 [7 - 25] versus 6 [4 - 12]; p < 0.001), higher hospital mortality (25.74% versus 5.11%; p < 0.001) and additional higher one-year mortality (5.3% versus 0.6%, p < 0.001). Delirium was classified by CAM-ICU-7 in terms of severity, and higher scores were associated with higher in-hospital mortality (17.86% versus 34.38% versus 38.46%, 95%CI, p value < 0.001). Severe delirium was associated with a higher risk of progression to coma (OR 7.1; 95%CI 1.9 - 31.0; p = 0.005) and to mechanical ventilation (OR 11.09; 95%CI 2.8 - 58.5; p = 0.002) in the multivariate analysis, adjusted by severity and frailty. In patients admitted with COVID-19 in the intensive care unit, delirium was an independent risk factor for the worst prognosis, including mortality. The delirium severity assessed by the CAM-ICU-7 during the first week in the intensive care unit was associated with poor outcomes, including progression to coma and to mechanical ventilation.

Safety and efficacy of methylprednisolone versus dexamethasone in critically ill patients with COVID-19 acute respiratory distress syndrome: a retrospective study.

Corticosteroids (CSs), specifically dexamethasone (DEX), are the treatment of choice for severe acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia (CARDS). However, data from both ARDS and relatively small CARDS clinical trials have suggested improved outcomes with methylprednisolone (MP) versus DEX. The objective of this retrospective cohort study was to compare the safety and effectiveness of MP and DEX in critically ill CARDS patients. The study cohort included CARDS patients admitted to a tertiary referral intensive care unit (ICU) between April and September 2020 who received at least 5 days of CSs for CARDS. The cohort was notable for a high severity of illness (overall, 88.5% of patients required mechanical ventilation and 16% required vasopressors on admission). The DEX group (n = 62) was significantly older with a higher illness severity [Sequential Organ Failure Assessment (SOFA) 6 (4.75-8) versus 4.5 (3-7), p = 0.008], while the MP group (n = 51) received significantly more loading doses [19 (37.3%) versus 4 (6.5%), p < 0.0001]. MP was associated with a shorter time to intubation and more rapid progression to mortality [days to death: 18 (15-23) versus 27 (15-34), p = 0.026]. After correction for baseline imbalances in age and SOFA score, DEX was associated with improved mortality at 90 days compared with MP [hazard ratio (HR) = 0.43, 95% confidence interval (CI) = 0.23-0.80, p = 0.008]. However, there were no differences between rates of secondary infections during hospitalization or insulin requirements at 7 and 14 days. In this cohort of critically ill CARDS, choice of CS was associated with mortality but not adverse event profile, and thus warrants further investigation.

Epidemiology, Risk Factors, and Outcome of Cardiac Dysrhythmias in a Noncardiac Intensive Care Unit.

Several extrinsic factors contribute to the development of cardiac dysrhythmias. In intensive care unit (ICU) settings and among critically ill patients who are exposed to a large number of risk factors, cardiac disturbances are more common. This study aimed to examine the epidemiology, risk factors, and outcome of cardiac dysrhythmias in a non-cardiac ICU. This is a retrospective, single-center, observational study conducted in a tertiary noncardiac ICU at Imam Khomeini Hospital in Ahvaz, Iran. Out of the 360 adult patients aged 18 years and older who were admitted to ICU for longer than 24 h, 340 cases who met the study inclusion criteria were recruited between March 2018 until October 2018. The most common nonsinus dysrhythmias were new-onset atrial fibrillation (NOAF) (12.9%) and ventricular tachycardia (21 patients-6.2%). According to our results, previous percutaneous coronary instrumentation, acute kidney injury, sepsis, and hyperkalemia act as risk factors in the development of cardiac dysrhythmias. Additionally, we found out that thyroid dysfunction and pneumonia can predict the development of NOAF in critically ill patients. The estimated mortality rate among patients with NOAF in this study was 15.7% (p < .05). Cardiac dysrhythmias are common in ICU patients and treating the risk factors can help to prevent their development and improve patient management and outcome.

Rationality of Use and Effectiveness of Stress Ulcer Prophylaxis in Critically Ill Patients: An Experience from A Tertiary Intensive Care Unit

Background: Stress-related mucosal disease (SRMD) frequently develops in critically ill patients, increasing mortality and length of intensive care unit (ICU) stay. There is limited data on stress ulcer prophylaxis (SUP) on critically ill patients in Indonesia.Objective:Methods: This is a retrospective cohort study of patients admitted to the ICU from January 1, 2015, to December 31, 2017. The subjects were all ICU patients who used proton pump inhibitor (PPI) and histamine-2 receptor antagonist (H2RA) as SUP therapy.Results: A total of 315 patients were included, and mean age was 48 years. Approximately 55.2% were women, and 62.8% of patients were admitted to ICU following high-risk surgery. PPI was given to 187 patients (59.4%) and H2RA to 128 patients (40.6%), with an average usage for 5 days. The incidence of SRMD was 15.9% (n = 50), and mean length of stay in the ICU was 6 days. Gender, age, duration of SUP, and ICU length of stay of the PPI and H2RA groups were not statistically different (p &gt; 0.05) and did not affect the GI event (p &gt; 0.05). The use of rational SUP was 98.4%. Major American Society of Health-System Pharmacists (ASHP) risk factor criterion was ventilator use (86.8%), while the minor ASHP criterion was anticoagulant therapy (22.2%). The incidence of GI event was significantly lower in PPI groups than H2RA groups (p &lt; 0.05).Conclusions: The use of SUP is rational with an average use of 5 days. PPI are superior to H2RA for SRMD prophylaxis.

Changing epidemiology of acute kidney injury in critically ill patients with COVID-19: a prospective cohort

BackgroundAcute kidney injury (AKI) is common in critically ill patients with coronavirus disease-19 (COVID-19). We aimed to explore the changes in AKI epidemiology between the first and the second COVID wave in the United Kingdom (UK).MethodsThis was an observational study of critically ill adult patients with COVID-19 in an expanded tertiary care intensive care unit (ICU) in London, UK. Baseline characteristics, organ support, COVID-19 treatments, and patient and kidney outcomes up to 90 days after discharge from hospital were compared.ResultsA total of 772 patients were included in the final analysis (68% male, mean age 56 ± 13.6). Compared with wave 1, patients in wave 2 were older, had higher body mass index and clinical frailty score, but lower baseline serum creatinine and C-reactive protein (CRP). The proportion of patients receiving invasive mechanical ventilation (MV) on ICU admission was lower in wave 2 (61% vs 80%; p < 0.001). AKI incidence within 14 days of ICU admission was 76% in wave 1 and 51% in wave 2 (p < 0.001); in wave 1, 32% received KRT compared with 13% in wave 2 (p < 0.001). Patients in wave 2 had significantly lower daily cumulative fluid balance (FB) than in wave 1. Fewer patients were dialysis dependent at 90 days in wave 2 (1% vs. 4%; p < 0.001).ConclusionsIn critically ill adult patients admitted to ICU with COVID-19, the risk of AKI and receipt of KRT significantly declined in the second wave. The trend was associated with less MV, lower PEEP and lower cumulative FB.Trial registration: NCT04445259.

Post-intensive Care Syndrome in a Heterogeneous Pediatric Population.

Background In this study, we aimed to measure the incidence of post-intensive care syndrome among children (PICS-p) who received critical care treatment in our hospital and evaluate patient characteristics and critical care interventions associated with the development of PICS-p. Methodology We conducted a retrospective cohort review ofall surviving pediatric patients admitted to an urban, academic, tertiary intensive care unit betweenJuly 2017 and June 2018. Based on the existing literature on PICS, we excluded children whose length of stay in the pediatric intensive care unit (PICU) was less than four days. We collected demographic data, clinical data, and data related to outcomes in our study cohort. We defined PICS-p a priori as a change in the Functional Status Scale (FSS) score of three or greater between pre-admission and discharge. Using Student's t-tests and Wilcoxon rank-sum tests, we compared outcomes among those with PICS-p versus those without PICS-p. Results Of the 183 patients, 36 (19.6%) were diagnosed with PICS in our study. Aside from pre-admission FSS (7 vs. 8), analysis of the two groups revealed no statistically significant difference before or at the time of admission. Upon admission to the PICU, statistically significant differences between the PICS and no PICS groups were noted in the hospital length of stay (33.5 days vs. 14.7 days), ventilation-free days (8.3 days vs. 5.2 days), and the number of procedural interventions (2.6 vs. 1). Conclusions Utilizing the FSS to determine PICS is a viable method to standardize the measurement of functional outcomes for critically ill children. In our single-center, retrospective review, nearly one out of five pediatric patients developed PICS with associated factors that included a decreased pre-hospital FSS score, increased hospital length of stay, fewer ventilation-free days, and increased number of procedural interventions. Significant opportunities exist regarding the social and psychiatric domains of PICS-p.

278: PRACTICE OF DO-NOT-RESUSCITATE ORDERS IN A TERTIARY CARE HOSPITAL IN SAUDI ARABIA

Introduction: The objective of the study is to describe DNR practices in Saudi Arabia. Methods: This is a retrospective cohort study based on a prospectively collected intensive care unit (ICU) database between 2002-2017. We compared patients who had DNR order during the ICU stay with patients with “full code” admitted to a tertiary medical-surgical ICU in Riyadh, Saudi Arabia. Results: Among 24790 patients admitted to the ICU over the 16-year period, 3217 (13%) patients had DNR orders during the ICU stay. Patients with DNR orders, compared to patients with “full code”, were older (median 67 years (Q1,Q3: 55,76) vs. 57 years (Q1,Q3: 33,71), P < 0.0001), were more likely to be females 1374 (43%) vs. 8200 (38%), P < 0.0001) and had higher APACHE II score (median 28 (Q1,Q3: 23, 34) vs. 19 (Q1,Q3: 13, 25), P < 0.0001). Patients with DNR orders, compared to patients with “full code”, were more likely to be mechanically ventilated (2660 (83%) vs. 11871 (55%), P < 0.0001), to have comorbid conditions and had a lower functional status (modified Rankin scores 4-5: 608 (18.9%) vs. 1897 (8.8%), P < 0.0001). Patients with DNR orders, compared to patients with “full code”, were more likely to die in the ICU (2168/3217 (67.8%) vs. 1807/21573 (8.5%) P < 0.0001); and in the hospital (2650/3217 (82.4%) vs. 3908/21573 (18.1%) P < 0.0001). On multivariate logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (OR 1.01, 95% CI 1.009, 1.014, P < 0.0001), higher APACHE II score (OR 1.09, 95% CI 1.008, 1.095, P < 0.0001), and increasing modified Rankin score. Patients admitted in the recent years (2012-2017 vs. 2002-2005) were less likely to have DNR orders (OR 0.36, 95% CI 0.33, 0.40, P < 0.0001). Conclusions: In a tertiary care ICU in Saudi Arabia, about 13% of patients had DNR orders. The study identified several predictors that were associated with the likelihood of DNR orders, including severity of illness and poor baseline functional status.

110: A RETROSPECTIVE REVIEW OF BEHAVIORAL MEDICINE CONSULTATION PATTERNS IN AN ICU BASED ON RACE

Introduction: Providing clinical psychological support for patients and their families during an intensive care unit (ICU) admission is an important practice. The addition of clinical psychologists to the multi-disciplinary team aids in addressing psychological symptoms associated with critical illness. Health care disparities amongst the critically-ill are well documented. The objective of this study is to determine if this resource was equitably distributed amongst all self-identified racial/ethnic groups (SIRG) in an urban tertiary care academic ICU. Methods: A retrospective review of the distribution of behavioral medicine consults for patients admitted to a mixed academic tertiary ICU based on SIRG was performed. The total number of patients who were admitted to the ICU, who died and who received a behavioral medicine consult were collected. Each group was divided based on the percent of each SIRG. Results: A total of 1822 patients in 2021 and 917 patients in 2022 were admitted to the ICU. Consultation rate was similar between the two years (24% of patients in 2021 and 23% of patients in 2022). The percentage of each SIRG who received consults was similar to the percentage of each SIRG who was admitted to the ICU (58% White, 21% Black, 12% Latinx/Hispanic, 2% Asian and 7% unknown). The mortality who received consults was similar amongst the races implying a similar consultation pattern (White 71%, Black 68%, Latinx 72%, Asian 60% and unknown 63%). Consultations were requested by the Critical Care Attendings. CCM faculty SIRG was as follows 64.8% White, 32% Asian, 3.5% Latinx/Hispanic. Conclusions: After implementation of a dedicated ICU clinical psychologist, equitable consultation can be provided during an ICU admission. Successful integration of Behavioral Medicine services relied on a multi-disciplinary approach, allowing social work, bedside nursing as well as physicians to request evaluation. More information regarding provider and patients’ beliefs about Behavioral Medicine services, use of alternative supports (e.g. family support, Pastoral Care), as well as the potential benefits needs to be determined. Monitoring and review of patterns should be performed to increase the understanding of these disparities in care and develop appropriate interventions.

985: EVALUATION OF DISCHARGE OPIOID PRESCRIBING IN MECHANICALLY VENTILATED ICU PATIENTS

Introduction: Opioids are a core component in the multimodal approach to patient analgesia during invasive mechanical ventilation (IMV). However, the implications of opioid use during IMV on prescribing opioids on hospital discharge is unknown. Methods: We conducted a retrospective cohort study of patients requiring IMV within a tertiary academic medical intensive care unit (MICU) to characterize hospital discharge opioid prescribing patterns between opioid-naive and opioid-users. We included patients that received at least 1 dose of opioid within the first 12-hours of IMV and required IMV for at least 24 hours. Patients were characterized as opioid-naïve or opioid-users based upon opioids prescribed prior to MICU admission. The primary outcome was the percentage of patients prescribed opioids at hospital discharge. Secondary outcomes included the morphine milligram equivalents (MME) per day during IMV, delirium-free days, correlation of pain (critical care pain observation tool (CPOT)) scores and MME during IMV, duration of IMV, and length of hospital stay (LOS). Results: One hundred sixty-seven consecutive patients presenting to the MICU were included. Of these, 128 (76.6%) were opioid-naïve and 39 (23.4%) were opioid-users. Median age was 59 years and 61.7% were Caucasian. More opioid-users had cancer compared to opioid-naïve (35.9% vs 14.8%, p< 0.001). Thirty-two (25%) opioid-naïve and 27 (69.2%) opioid-users were prescribed opioids on discharge. The mean MME prescribed at discharge was higher in opioid-users, compared to opioid-naive (77.2 vs 16.4, p< 0.001). The median quantity of opioids prescribed during IMV did not differ between groups (465 MME in opioid-naïve vs. 467 MME in opioid-user, p=0.49). Median daily CPOT scores did not correlate with MME or dose titrations. There was no difference in duration of IMV or LOS between groups. Opioid-naïve patients had less delirium-free days, compared to opioid-users (0.68 vs. 1.13, p=0.003). Conclusions: Our study found 25% of opioid-naïve patients undergoing IMV were discharged from the hospital on opioids and the daily CPOT score did not correlate with MME and dose titration. It is unclear why 25% of opioid-naïve patients who underwent IMV in a MICU required opioids at hospital discharge and is an area that warrants further investigation.

905: POST-INTUBATION PARTIAL PRESSURE OF O2/FRACTION OF INSPIRED O2 AND IN-HOSPITAL MORTALITY IN COVID-19

Introduction: Early determinants of clinical outcome for SARS-CoV-2 infection (COVID-19) and pneumonia remain a critical need to guide patient management, goals of care discussions, and resource allocation in times of surges. Our hypothesis, there is an association between the Partial pressure of oxygen/Fraction of inspired oxygen (P:F) ratio immediately after intubation in patients with COVID-19 respiratory failure and in-hospital mortality. Methods: This is a cross sectional retrospective observational study in an urban academic tertiary care intensive care unit (ICU). The study was approved by the University’s Institutional Review Board. Patients included in the study were admitted to the medical ICU who tested positive for SARS-CoV-2 requiring escalation of care with intubation and placement on mechanical ventilation. Patients less than 18 years of age or who were pregnant were excluded from the study. Data analysis was conducted using Stata 17.0 software. Univariate logistic regression analyses of the independent variables on the primary outcome were used individually and odds ratios with confidence intervals calculated. Results: The inclusion criteria were met in 78 patients of which two patients were excluded from the study due to multiple missing data points. Participants had an average age of 57.3 years with 68% under 65 and 78% male. The majority of patients (54%) had a BMI ≥30 while 51% had a history of diabetes. Only 14% had a history of chronic kidney disease. Fifty percent of the total sample had Initial post-intubation P:F ratio values < 100 and 50% had values ≥100. Total in-hospital mortality for all patients through the period of observation was 49%. Patients with a P:F ratio of < 100 had 100% increased odds of in-patient mortality. The OR was 2.1 for in-hospital mortality for patients with P:F ratio < 100 (58%), versus those with P:F ratio ≥100 (39%), [95% CI, 0.84 to 5.27], p = 0.11. Bivariate logistic regression analyses for association of in-hospital mortality with individual independent variables did not show significance. Conclusions: The odds of in-hospital mortality is higher when immediate post-intubation P:F ratio is < 100. While this did not reach statistical significance due to the limited size of the study, it remains of clinical interest and warrants further investigation.

Activin A level is associated with physical function in critically ill patients

BackgroundActivin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels. ObjectivesThe objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital. MethodsThirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU. ResultsHigh peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: −91.3, −154.2 to −28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures. ConclusionsHigher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness. Study registrationACTRN12615000047594.