Therapeutic Intervention Scoring System Research Articles

Effect of mortality prediction models on resource use benchmarking of intensive care units

PurposeIntensive care requires extensive resources. The ICUs' resource use can be compared using standardized resource use ratios (SRURs). We assessed the effect of mortality prediction models on the SRURs. Materials and methodsWe compared SRURs using different mortality prediction models: the recent Finnish Intensive Care Consortium (FICC) model and the SAPS-II model (n = 68,914 admissions). We allocated the resources to severity of illness strata using deciles of predicted mortality. In each risk and year stratum, we calculated the expected resource use per survivor from our modelling approaches using length of ICU stay and Therapeutic Intervention Scoring System (TISS) points. ResultsResource use per survivor increased from one length of stay (LOS) day and around 50 TISS points in the first decile to 10 LOS-days and 450 TISS in the tenth decile for both risk scoring systems. The FICC model predicted mortality risk accurately whereas the SAPS-II grossly overestimated the risk of death. Despite this, SRURs were practically identical and consistent. ConclusionsSRURs provide a robust tool for benchmarking resource use within and between ICUs. SRURs can be used for benchmarking even if recently calibrated risk scores for the specific population are not available.

COVID-19 Is an Independent Risk Factor for Detrimental Invasive Fungal Disease in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: A Retrospective Study.

Invasive fungal disease (IFD) is associated with the mortality of patients on extracorporeal membrane oxygenation (ECMO). Several risk factors for IFD have been identified in patients with or without ECMO. Here, we assessed the relevance of coronavirus disease (COVID-19) for the occurrence of IFD in patients on veno-venous (V-V) ECMO for respiratory failure. In a retrospective analysis of all ECMO cases between January 2013 and December 2022 (2020-2022 for COVID-19 patients), active COVID-19 and the type, timing and duration of IFD were investigated. Demographics, hospital, ICU length of stay (LoS), duration of ECMO, days on invasive mechanical ventilation, prognostic scores (Respiratory ECMO Survival Prediction (RESP) score, Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS)-10, Sequential Organ Failure Assessment (SOFA) score and Simplified Acute Physiology Score (SAPS)-II) and length of survival were assessed. The association of COVID-19 with IFD was investigated using propensity score matching and uni- and multivariable logistic regression analyses. We identified 814 patients supported with ECMO, and 452 patients were included in further analyses. The incidence of IFD was 4.8% and 11.0% in patients without and with COVID-19, respectively. COVID-19 status represented an independent risk factor for IFD (OR 4.30; CI 1.72-10.85; p: 0.002; multivariable regression analysis). In patients with COVID-19, 84.6% of IFD was candidemia and 15.4% represented invasive aspergillosis (IA). All of these patients died. In patients on V-V ECMO, we report that COVID-19 is an independent risk factor for IFD, which is associated with a detrimental prognosis. Further studies are needed to investigate strategies of antifungal therapy or prophylaxis in these patients.

Carga laboral en áreas críticas y “TISS 28”

Introduction: nursing as the backbone of the global health care system. The workload in critical care units affects the quality of health care. The creation of therapeutic support units for medical specialties has increased their complexity. The Simplified Therapeutic Intervention Scoring System (TISS-28) determines workload. The lack or absence of the application of these tools within the ICU has evidenced a workload and caused adverse effects for the external and internal user. Objective: to determine the nursing workload by means of the TISS-28 Prognostic System in the Intensive Care Unit of the Hospital General Docente Ambato. Methods: a prospective, descriptive, cross-sectional, correlational, descriptive study was conducted during the period from June to August 2019; in the Intensive Care Unit of the Hospital General Docente Ambato. Results: there is a deficit of nursing staff in the shift from 19 to 35%. The workload increases adverse events: Health Care Associated Infections, medication errors, deteriorating the quality of health care. Multiplying the workload of nursing staff in Intensive Care Units. Conclusions: The TISS-28 scale has proven to be a reliable method to determine and distribute workload. Workload increased adverse events deteriorating the quality of health and the incidence of burnout syndrome in health care personnel.

Variation in Severity-Adjusted Resource use and Outcome for Neurosurgical Emergencies in the Intensive Care Unit

BackgroundThe correlation between the standardized resource use ratio (SRUR) and standardized hospital mortality ratio (SMR) for neurosurgical emergencies is not known. We studied SRUR and SMR and the factors affecting these in patients with traumatic brain injury (TBI), nontraumatic intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH).MethodsWe extracted data of patients treated in six university hospitals in three countries (2015–2017). Resource use was measured as SRUR based on purchasing power parity-adjusted direct costs and either intensive care unit (ICU) length of stay (costSRURlength of stay) or daily Therapeutic Intervention Scoring System scores (costSRURTherapeutic Intervention Scoring System). Five a priori defined variables reflecting differences in structure and organization between the ICUs were used as explanatory variables in bivariable models, separately for the included neurosurgical diseases.ResultsOut of 28,363 emergency patients treated in six ICUs, 6,162 patients (22%) were admitted with a neurosurgical emergency (41% nontraumatic ICH, 23% SAH, 13% multitrauma TBI, and 23% isolated TBI). The mean costs for neurosurgical admissions were higher than for nonneurosurgical admissions, and the neurosurgical admissions corresponded to 23.6–26.0% of all direct costs related to ICU emergency admissions. A higher physician-to-bed ratio was associated with lower SMRs in the nonneurosurgical admissions but not in the neurosurgical admissions. In patients with nontraumatic ICH, lower costSRURs were associated with higher SMRs. In the bivariable models, independent organization of an ICU was associated with lower costSRURs in patients with nontraumatic ICH and isolated/multitrauma TBI but with higher SMRs in patients with nontraumatic ICH. A higher physician-to-bed ratio was associated with higher costSRURs for patients with SAH. Larger units had higher SMRs for patients with nontraumatic ICH and isolated TBI. None of the ICU-related factors were associated with costSRURs in nonneurosurgical emergency admissions.ConclusionsNeurosurgical emergencies constitute a major proportion of all emergency ICU admissions. A lower SRUR was associated with higher SMR in patients with nontraumatic ICH but not for the other diagnoses. Different organizational and structural factors seemed to affect resource use for the neurosurgical patients compared with nonneurosurgical patients. This emphasizes the importance of case-mix adjustment when benchmarking resource use and outcomes.

Associations between Early Thyroid-Stimulating Hormone Levels and Morbidities in Extremely Preterm Neonates

Introduction: High-end cutoffs of thyroid-stimulating hormone (TSH) have been emphasized for hypothyroidism therapy in extremely preterm infants, but the significance of low TSH levels remains unknown. This study hypothesized that the spectrum of TSH levels by newborn screening after birth signifies specific morbidities in extremely preterm neonates. Methods: The multicenter population cohort analyzed 434 extremely preterm neonates receiving TSH screening at 24–96 h of age in 2008–2019. Neonates were categorized by blood TSH levels into group 1: TSH <0.5 µU/mL, group 2: 0.5 ≤ TSH <2 µU/mL, group 3: 2 ≤ TSH <4 µU/mL, and group 4: TSH ≥4 µU/mL. Neonatal morbidities were categorized using the modified Neonatal Therapeutic Intervention Scoring System. Results: The four groups differed in gestational age, birth weight, and the postnatal age at blood sampling so did the proportions of mechanical ventilation usage (p = 0.01), hypoxic respiratory failure (p = 0.005), high-grade intraventricular hemorrhage (p = 0.007), and periventricular leukomalacia (p = 0.048). Group 1 had higher severity scores for respiratory distress syndrome (RDS; effect size 0.39 [95% confidence interval [CI]: 0.18–0.59]) and brain injury (0.36 [0.15–0.57]) than group 2, which remained significant after adjusting for gestational age, birth weight, dopamine usage, and the postnatal age at TSH screening (RDS: mean + 0.45 points [95% CI: 0.11–0.79]; brain injury: +0.32 [0.11–0.54]). Conclusions: Low TSH levels in extremely preterm neonates are associated with severe RDS and brain injuries. Studies recruiting more neonates with complete thyroid function data are necessary to understand central-peripheral interactions of the hypothalamic-pituitary-thyroid axis.

Impact of cardiac surgery and neurosurgery patients on variation in severity-adjusted resource use in intensive care units.

The resource use of cardiac surgery and neurosurgery patients likely differ from other ICU patients. We evaluated the relevance of these patient groups on overall ICU resource use. Secondary analysis of 69,862 patients in 17 ICUs in Finland, Estonia, and Switzerland in 2015-2017. Direct costs of care were allocated to patients using daily Therapeutic Intervention Scoring System (TISS) scores and ICU length of stay (LOS). The ratios of observed to severity-adjusted expected resource use (standardized resource use ratios; SRURs), direct costs and outcomes were assessed before and after excluding cardiac surgery or cardiac and neurosurgery. Cardiac surgery and neurosurgery, performed only in university hospitals, represented 22% of all ICU admissions and 15-19% of direct costs. Cardiac surgery and neurosurgery were excluded with no consistent effect on SRURs in the whole cohort, regardless of cost separation method. Excluding cardiac surgery or cardiac surgery plus neurosurgery had highly variable effects on SRURs of individual university ICUs, whereas the non-university ICU SRURs decreased. Cardiac and neurosurgery have major effects on the cost structure of multidisciplinary ICUs. Extending SRUR analysis to patient subpopulations facilitates comparison of resource use between ICUs and may help to optimize resource allocation.

Incidence and Outcomes of Cardiopulmonary Resuscitation in ICUs: Retrospective Cohort Analysis.

We aim to describe incidence and outcomes of cardiopulmonary resuscitation (CPR) efforts and their outcomes in ICUs and their changes over time. Retrospective cohort analysis. Patient data documented in the Austrian Center for Documentation and Quality Assurance in Intensive Care database. Adult patients (age ≥ 18 yr) admitted to Austrian ICUs between 2005 and 2019. None. Information on CPR was deduced from the Therapeutic Intervention Scoring System. End points were overall occurrence rate of CPR in the ICU and CPR for unexpected cardiac arrest after the first day of ICU stay as well as survival to discharge from the ICU and the hospital. Incidence and outcomes of ICU-CPR were compared between 2005 and 2009, 2010 and 2014, and 2015 and 2019 using chi-square test. A total of 525,518 first admissions and readmissions to ICU of 494,555 individual patients were included; of these, 72,585 patients (14.7%) died in hospital. ICU-CPR was performed in 20,668 (3.9%) admissions at least once; first events occurred on the first day of ICU admission in 15,266 cases (73.9%). ICU-CPR was first performed later during ICU stay in 5,402 admissions (1.0%). The incidence of ICU-CPR decreased slightly from 4.4% between 2005 and 2009, 3.9% between 2010 and 2014, and 3.7% between 2015 and 2019 ( p < 0.001). A total of 7,078 (34.5%) of 20,499 patients who received ICU-CPR survived until hospital discharge. Survival rates varied slightly over the observation period; 59,164 (12.0%) of all patients died during hospital stay without ever receiving CPR in the ICU. The incidence of ICU-CPR is approximately 40 in 1,000 admissions overall and approximately 10 in 1,000 admissions after the day of ICU admission. Short-term survival is approximately four out of 10 patients who receive ICU-CPR.

A New Quantitative Triage System for Hospitalized Neonates to Assist with Decisions of Hospital Evacuation Priorities.

Hospitalized neonates are vulnerable to natural and man-made disasters because of their persistent requirement for medical resources and may need to be evacuated to safe locations when electricity and medical gas supply become unreliable. In Japan, a triage system for hospitalized neonates, or the Simple Triage and Rapid Treatment for Neonates, Revised (START-Neo-R), has been used to determine whether neonates are in suitable conditions for transportation. However, this scale is not useful to determine the evacuation order of neonates because a considerable number of evacuees are classified into the same categories. To solve this problem, a novel triage system, Neonatal Extrication Triage (NEXT) was developed. This study tested the validity and reproducibility of both triages and compared them with a standardized prognostic scoring system for hospitalized neonates, the Neonatal Therapeutic Intervention Scoring System (NTISS). In this retrospective observational study, physicians and nurses independently assessed each neonate hospitalized at a tertiary neonatal intensive care unit (NICU) twice weekly using NEXT and START-Neo-R. The NEXT system comprises six questionnaires regarding medical resources required during transition and transportation, providing composite scores on a 12-point scale. The START-Neo-R classified neonates into five levels based on the severity of disease and dependence on medical care. Inter-rater reliability of both systems was assessed using Cohen's kappa coefficient, whereas the criterion validity with NTISS was assessed using Spearman's correlation coefficient. Overall, 162 neonates were assessed for 49 days, resulting in triage data for 1,079 accumulated patients. Both NEXT scores and START-Neo-R ranks were well-dispersed across different levels without excessive accumulation in specific categories. Inter-rater reliability of NEXT (kappa coefficient, 0.973; 95% confidence interval, 0.969-0.976) and START-Neo-R (kappa coefficient, 0.952; 95% confidence interval, 0.946-0.957) between physicians and nurses was sufficiently high. The correlation coefficient of NEXT and START-Neo-R scores with NTISS scores were 0.889 (P <.001) and 0.850 (P <.001), respectively. Both START-Neo-R and NEXT had good reproducibility and correlation with the severity of neonates indicated by NTISS. With its well-dispersed scores across different levels, the NEXT system might be a powerful tool to determine the priority of evacuation objectively.

Impact of Invasive Fungal Diseases on Survival under Veno-Venous Extracorporeal Membrane Oxygenation for ARDS.

Objective: To assess the incidence and significance of invasive fungal diseases (IFD) during veno-venous (VV) ECMO support for acute respiratory distress syndrome (ARDS). Methods: Retrospective analysis from January 2013 to April 2021 of all ECMO cases for ARDS at a German University Hospital. In patients with IFD (IFD patients), type of IFD, time of IFD, choice of antifungal agent, duration, and success of therapy were investigated. For comparison, patients without IFD (non-IFD patients) were selected by propensity score matching using treatment-independent variables (age, gender, height, weight, and the Sequential Organ Failure Assessment (SOFA) score at ICU admission). Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, prognostic scores (Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS), and length of survival were assessed. Results: A total of 646 patients received ECMO, 368 patients received VV ECMO. The incidence of IFD on VV ECMO was 5.98%, with 5.43% for Candida bloodstream infections (CBSI) and 0.54% for invasive aspergillosis (IA). In IFD patients, in-hospital mortality was 81.8% versus 40.9% in non-IFD patients. The hazard ratio for death was 2.5 (CI 1.1–5.4; p: 0.023) with IFD. Conclusions: In patients on VV ECMO for ARDS, about one in 17 contracts an IFD, with a detrimental impact on prognosis. Further studies are needed to address challenges in the diagnosis and treatment of IFD in this population.

Predicting the Risk of Mortality in Children using a Fuzzy-Probabilistic Hybrid Model.

Introduction The mortality risk in children admitted to Pediatric Intensive Care Units (PICU) is usually estimated by means of validated scales, which only include objective data among their items. Human perceptions may also add relevant information to prognosticate the risk of death, and the tool to use this subjective data is fuzzy logic. The objective of our study was to develop a mathematical model to predict mortality risk based on the subjective perception of PICU staff and to evaluate its accuracy compared to validated scales. Methods A prospective observational study in two PICUs (one in Spain and another in Latvia) was performed. Children were consecutively included regardless of the cause of admission along a two-year period. A fuzzy set program was developed for the PICU staff to record the subjective assessment of the patients' mortality risk expressed through a short range and a long range, both between 0% and 100%. Pediatric Index of Mortality 2 (PIM2) and Therapeutic Intervention Scoring System 28 (TISS28) were also prospectively calculated for each patient. Subjective and objective predictions were compared using the logistic regression analysis. To assess the prognostication ability of the models a stratified B-random K-fold cross-validation was performed. Results Five hundred ninety-nine patients were included, 308 in Spain (293 survivors, 15 nonsurvivors) and 291 in Latvia (282 survivors, 9 nonsurvivors). The best logistic classification model for subjective information was the one based on MID (midpoint of the short range), whereas objective information was the one based on PIM2. Mortality estimation performance was 86.3% for PIM2, 92.6% for MID, and the combination of MID and PIM2 reached 96.4%. Conclusions Subjective assessment was as useful as validated scales to estimate the risk of mortality. A hybrid model including fuzzy information and probabilistic scales (PIM2) seems to increase the accuracy of prognosticating mortality in PICU.

Association of thyroid hormones and thyroid-stimulating hormone with mortality in adults admitted to the intensive care unit: A systematic review and meta-analysis.

Thyroid hormones (THs) and thyroid-stimulating hormone (TSH) seem to show high potential in predicting the clinical death outcome of patients admitted to the intensive care unit (ICU). However, diverse studies on this topic are conflicting. A search was conducted by two investigators involved in this research in the PubMed, Embase, and Cochrane databases (all last launched on July 12, 2021). The quality of the included studies was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). Subgroup analyses were performed to determine the sources of heterogeneity. Sensitivity and publication bias analyses were also assessed. A total of 27 studies (4970 participants) were included based on the eligibility criteria. Compared with survivors, nonsurvivors were found to have lower levels of THs (T3, T4, fT3, and fT4), whereas no significant difference was found in TSH levels (13 studies for T3: standardized mean differences [SMD], -0.78; 95% CI, -1.36 to -0.20; I2 = 96%; p = 0.008; 11 studies for T4: SMD = -0.79; 95% CI, -1.31 to -0.28; I2 =95%; p = 0.0002; 14 studies for fT3: SMD = -0.76; 95% CI, -1.21 to -0.32; I2 = 95%; p = 0.0008; 17 studies for fT4: SMD = -0.60; 95% CI, -0.99 to -0.22; I2 = 95%; p = 0.002; 20 studies for TSH: SMD = 0.00; 93% CI, -0.29 to 0.29; I2 = 93%; p = 0.98). Nonsurvivors were associated with lower levels of THs (T3, T4, fT3, and fT4) than survivors. THs show great application potential in predicting ICU patients' death outcomes and improving already widely used prognostic scores in the ICU (ie, Acute Physiological and Chronic Health Evaluation [APACHE] II and Therapeutic Intervention Scoring System).

Comparative assessment of acceptability of the prognostic scales in predicting the risk of interhospital evacuation of newborns

BACKGROUND: The safety of interhospital transfer of newborns remains one of the most important issues of emergency neonatology. Assessment of risks associated with transfer is the basic concern of pre-transport preparation.&#x0D; AIM: This study aimed to assess and compare the predictive value of the KSCHONN, National Therapeutic Intervention Scoring System (NTISS), and TRIPS scales in predicting the risks associated with the interhospital transfer of newborns.&#x0D; MATERIALS AND METHODS: The cohort study included data from 604 visits of the transport team. The KSHONN, NTISS, and TRIPS scales were used in the assessments, the therapeutic actions of the transport team during transfer were evaluated, and mortality during the first day after assessments was analyzed. The area under the receiver operating characteristic curve (AUC ROC) was calculated for the KSCHONN, NTISS, and TRIPS scales in relation to the therapeutic actions of the transport team and first-day mortality.&#x0D; RESULTS: The predictive values of the KSHONN and TRIPS scales for additional infusion reflected AUC ROC values of 0.877 (0.4361.317) and AUC ROC 0.889 (0.4681.311), respectively. The AUC ROC value for predicting catecholamine dose adjustment or appointment and correction of ventilation for all three scales was less than 0.8. The predictive value of all three scales in the prediction of death on the day after the assessment of the transport team is high, and the TRIPS scale had the highest AUC ROC [0.988 (0.9770.999)], which was significantly higher than that for the NTISS scale 0.875 (0.7900.959) (p = 0.004). The KSHONN scale demonstrated a better predictive value for daily mortality [0.984 (0.8611.003)] in comparison with NTISS (p = 0.001). The risk ratio of the daily mortality in the group of patients with an assessment of 94 points according to KSHONN in comparison with patients with an assessment of 68 points was 17.73 (0.88355.8).&#x0D; CONCLUSIONS: The evaluated scales predict patient death within a day after the assessment of the transport team with good accuracy, and the KSHONN and TRIPS scales predict the need for additional infusion during transfer. However, none of the scales predict other actions of the team associated with the deterioration of the patients condition during transfer with the required accuracy.

Variation in severity-adjusted resource use and outcome in intensive care units

PurposeIntensive care patients have increased risk of death and their care is expensive. We investigated whether risk-adjusted mortality and resources used to achieve survivors change over time and if their variation is associated with variables related to intensive care unit (ICU) organization and structure.MethodsData of 207,131 patients treated in 2008–2017 in 21 ICUs in Finland, Estonia and Switzerland were extracted from a benchmarking database. Resource use was measured using ICU length of stay, daily Therapeutic Intervention Scoring System Scores (TISS) and purchasing power parity-adjusted direct costs (2015–2017; 17 ICUs). The ratio of observed to severity-adjusted expected resource use (standardized resource use ratio; SRUR) was calculated. The number of expected survivors and the ratio of observed to expected mortality (standardized mortality ratio; SMR) was based on a mortality prediction model covering 2015–2017. Fourteen a priori variables reflecting structure and organization were used as explanatory variables for SRURs in multivariable models.ResultsSMR decreased over time, whereas SRUR remained unchanged, except for decreased TISS-based SRUR. Direct costs of one ICU day, TISS score and ICU admission varied between ICUs 2.5–5-fold. Differences between individual ICUs in both SRUR and SMR were up to > 3-fold, and their evolution was highly variable, without clear association between SRUR and SMR. High patient turnover was consistently associated with low SRUR but not with SMR.ConclusionThe wide and independent variation in both SMR and SRUR suggests that they should be used together to compare the performance of different ICUs or an individual ICU over time.

Intensive Care Unit (ICU) Readmission: A Mixed- Method Systematic Review

Objective: This review aimed to determine the issue associated with patient’s readmission to intensive care units (ICU) within 24 to 72 hours. Methods: A mixed-method systematic literature review was carried out with 16 articles which published within the year of 2010 to 2020. Result: Three themes were found related to ICU readmission; predictors, factors, and recommendation. The predictors were Acute Physiological Chronic Health Evaluation (APACHE), Stability and Workload Index for Transfer (SWIFT), Therapeutic Intervention Scoring System (TISS) and others. The factors contributing to ICU readmission which are higher score level of tools used, severity of illness, discharge time, hemodynamic monitoring and patient’s conditions before discharge. The recommendations to reduce the ICU readmission from this review were ICU follow-up program, new staff nurses should be supported by senior staff, change of ICU discharge process, and introduce an intermediate unit. Conclusion: This review findings recommended that there is a need for a follow-up program by ICU nurse-led, the use of semi-intensive units and implementing transition programs of critical care for patients readmitted to ICU within 72 hours. Thus, more effort should be made to reduce the ICU readmission within 24 to 72 hours to improve the quality of patient’s life.

Temperature rhythms and ICU sleep: the TRIS study.

Core body temperature (CBT) patterns associated with sleep have not been described in the critically ill. This study aimed to characterize night-time sleep and its relationship to CBT in ICU patients. A prospective study was performed in a 27-bed tertiary adult intensive care unit of 20 mechanically ventilated patients in the weaning stage of their critical illness. The study assessed sleep by polysomnography (PSG) during the evening between 21:00-7:00 hours, nursing interventions using the Therapeutic Intervention Scoring System (TISS), illness severity using SOFA and APACHE II scores and CBT 24-hour pattern. Patients were awake for approximately half the study period (45.04%, IQR 13.81-77-17) with no REM (0%, IQR 0-0.04%) and median arousals of 19.5/hour (IQR 7.1-40.9). The 24-hour CBT had a rhythmic pattern in 13 (65%) patients with a highly variable phase of median peak time at 17:35 hours (IQR 12:40-19:39). No significant associations were found between CBT rhythmicity, sleep stages, sleep EEG frequency density, illness severity scores or TISS on the day of PSG. There was no relationship between time awake and CBT rhythmicity (P=0.48) or CBT peak time (P=0.82). The relationship between circadian rhythms and sleep patterns in the critically ill is complex. Patients recovering in ICU commonly have CBT loss of rhythmicity or a significant phase shift with loss of normal night-time patterns of sleep architecture. Appropriate care plans to promote sleep and circadian rhythm require further investigation of contributing factors such as environment, clinical care routines, illness type and severity.

The presence of liver cirrhosis is a strong negative predictor ofsurvival for patients admitted to the intensive care unit - Cirrhosis in intensive care patients.

Liver cirrhosis is a systemic disease that substantially impacts the body's physiology, especially in advanced stages. Accordingly, the outcome of patients with cirrhosis requiring intensive care treatment is poor. We aimed to analyze the impact of cirrhosis on mortality of intensive care unit (ICU) patients compared to other frequent chronic diseases and conditions. In this retrospective study, patients admitted over three years to the ICU of the Department of Medicine of the University Hospital Frankfurt were included. Patients were matched for age, gender, pre-existing conditions, simplified acute physiology score (SAPS II), and therapeutic intervention scoring system (TISS). A total of 567 patients admitted to the ICU were included in the study; 99 (17.5 %) patients had liver cirrhosis. A total of 129 patients were included in the matched cohort for the sensitivity analysis. In-hospital mortality was higher in cirrhotic patients than non-cirrhotic patients (p < 0.0001) in the entire and matched cohort. Liver cirrhosis remained one of the strongest independent predictors of in-hospital mortality (entire cohort p = 0.001; matched cohort p = 0.03) along with dialysis and need for transfusion in the multivariate logistic regression analysis. Furthermore, in the cirrhotic group, the need for kidney replacement therapy (p < 0.001) and blood transfusion (p < 0.001) was significantly higher than in the non-cirrhotic group. CONCLUSIONS: In the presented study, liver cirrhosis was one of the strongest predictors of in-hospital mortality in patients needing intensive care treatment along with dialysis and the need for ventilation. Therefore, concerted efforts are needed to improve cirrhotic patients' outcomes, prevent disease progression, and avoid complications with the need for ICU treatment in the early stages of the disease.

A review of inpatient nursing workload measures.

Fiscal constraints, an ageing populations and the increasing burden of chronic conditions are stressing health systems internationally. Nurses are the linchpin of effective healthcare delivery and their success is dependent on adequate staffing models, which must align knowledge, skills and competencies with workload. To compare measures of nursing workload in adult inpatient settings. A review of published studies characterising nursing workload measures was undertaken. Databases-PubMed and CINHAL-were used to identify published studies. A description of the psychometric properties of each measure and its use in an inpatient setting was required for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to guide and report the review. Of the 1,422 studies identified, 15 met the inclusion criteria. Nursing workload was measured in the intermediate care unit (n=6), overall hospital (n=7), emergency department (n=1) and burn unit (n=1) settings and also by mailed survey (n=1). Eleven different workload measures were identified. The National Aeronautics and Space Administration Task Load Index (n=3), Therapeutic Intervention Scoring System (n=3) and Nursing Activities Score (n=2) were the most common nursing workload measures identified with reported psychometric properties. Researchers, clinicians and hospital administrators should carefully identify and assess the psychometric properties of nursing workload measures before using these in routine practice. Gaining a consensus on effective nursing workload measures is a crucial step in designing appropriate staffing models and policies, improving nurse productivity and well-being, as well as enhancing patient health outcomes in inpatient settings.

Nursing workload assessment in an intensive care unit: A 5-year retrospective analysis.

To study the correlation between the workload of intensive care nursing teams and the sociodemographic, anthropometric and clinical characteristics of patients in critical condition in a Portuguese Intensive Care Unit (ICU) during a 5-year period. Currently, indices of nursing workload quantification are one of the resources used for planning and evaluating ICUs. Evidence shows that there are several factors related to critical patients and their hospitalisation which potentially influence the nursing workload. Retrospective cohort analysis of a health record database from adult patients admitted to a Portuguese ICU between 1 January 2015-31 December 2019. Simplified Therapeutic Intervention Scoring System (TISS-28) scores of 730 adult patients. Three TISS-28 assessments were considered: first assessment, last assessment and average. The STROBE guidelines were used in reporting this study. The TISS-28 has an average of 34.2±6.9 points at admission, which is considered a high nursing workload. A somewhat lower result was found for the discharge and average assessments. It shows that basic activities accounted for the highest percentage of time spent (38.0%), followed by the cardiovascular support category (26.5%). The TISS-28 shows consistent results throughout the study period, despite a small trend reduction in the last 2years. Lower workloads were found for age ≤44years and with a shorter length of stay. Higher workload was more probable in patients classified in Cullen Class IV (OR=2.5) and with a normal to higher weight percentile (OR=1.9 and 1.5, respectively). Knowledge of the factors influencing the nursing workload facilitates the implementation of rules to improve performance in nursing interventions, based on the redefinition of care priorities, increased productivity, human resources management and reduction of additional costs to the organisation, related to possible adverse events, among others.

Comparison of nursing workload in a Pediatric Intensive Care Unit estimated by three instruments.

To compare the nursing workload using the Nursing Activities Score (NAS), Therapeutic Intervention Scoring System-28 (TISS-28) and Nine Equivalents of Nursing Manpower Use Score (NEMS) instruments in children admitted to a Pediatric Intensive Care Unit in a university hospital. A prospective cohort study performed in a Pediatric Intensive Care Unit, with a sample formed of all children hospitalized during the study period. Nursing workload was evaluated using the TISS-28, NEMS and NAS instruments, and further divided into two groups: Group 1 forming a category of basic activities items and Group 2 forming a category of other support and intervention activities. The sample consisted of 490 Pediatric Intensive Care Unit admissions, totaling 4617 observations. NAS presented the best estimate of total working hours. TISS-28 and NEMS showed better agreement and the results showed strong correlations between NAS and TISS-28 and between NEMS and TISS-28. In Group 1 (basic activities), NAS(1) and TISS-28(1) showed moderate correlation, in Group 2 (specialized activities) the three instruments showed strong correlations. NAS stood out in the evaluation of nursing workload and showed good correlation and agreement with the TISS-28.

Development of Case Numbers during the COVID-19 Pandemic in a Center of Maximum-Care for Traumatology and Orthopedic Oncology.

(1) Background: The COVID-19 pandemic has led to a significant change in the utilization of trauma surgery and tumor orthopedic hospital facilities. (2) Methods: In a monocentric retrospective analysis, the weekly numbers of cases requiring intra-clinical treatment in the first four months of 2020 were compared with those of 2019. Patients’ visits to the emergency department and shock room, consultation hours, work-related accidents, case numbers in the normal and intensive care units, ventilation hours, the “Simplified Acute Physiology Score/ Therapeutic Intervention Scoring System” (SAPS/TISS), the average length of stay in hospital, the number of operations and their degree of urgency, as well as deaths, were analyzed in a study based on the data from 7606 outpatient consultations in 2019 and 6755 in 2020, as well as 993 inpatient cases in 2019 and 950 in 2020. (3) Results: There was a significant reduction in the number of treatments per week in the emergency department (261 ± 29 vs. 165 ± 25; p < 0.001) with the same number of shock room treatments and fewer consultation hour contacts (226 ± 29 vs. 119 ± 65; p = 0.012). There were fewer inpatient cases (66 ± 7 vs. 42 ± 11; p = 0.001), resulting in a fall in the days of hospitalization (492 ± 63 vs. 308 ± 78; p < 0.001) and number of operations (73 ± 7 vs. 55 ± 10; p = 0.012), especially elective procedures (20 ± 3 vs. 7 ± 7; p = 0.008). The SAPS/TISS score was lower (1351 ± 1213 vs. 399 ± 281; p = 0.023). Fewer fracture treatments and septic surgeries were performed, while the number of procedures to treat orthopedic malignancies remained constant. (4) Conclusions: During the first phase of the COVID-19 pandemic, we observed a significant reduction in the number of cases treated in orthopedics. While the number of multiple-injured patients was unchanged, fewer patients presented for primary and regular care. Treatment of acute injuries and malignant tumor diseases was not at risk. There was no effect on in-house mortality. We see a potential for the recruitment of medical staff from the outpatient department, operating room, and the ward. In the event of a future second wave, our results may allow for early planning, particularly of the all-important human resources. Reorganization by hospitals and decreased patient numbers in trauma surgery can enable the reallocation of medical staff, equipment, and beds to increase capacity for COVID-19 patients.