Use Of Intensive Care Services Research Articles

Biomarkers can Predict COVID-19 Disease

Abstract:: Health professionals have been confronted with a series of challenges because of the ongoing pandemic of coronavirus disease 2019 (COVID-19). To save the greatest number of lives possible, it is essential to make a prompt diagnosis and admission to the hospital, as well as to stratify risks, make efficient use of intensive care services, choose appropriate treatments, monitor patients, and ensure a prompt discharge. Laboratory markers, also known as biomarkers, can provide additional information that is objective and has the potential to significantly influence various aspects of patient care. Clinical assessment is necessary, but laboratory markers can provide this information. The COVID-19 virus is not an infection that causes the respiratory system; rather, it is a multisystem disease that is caused by a diffuse system-wide process that involves a complex interplay of the immune, nervous, and endocrine systems in inflammatory and coagulative cascades. A wide variety of potential biomarkers have been uncovered because of a better understanding of the virus's effects on the body and how the body responds to them. Here, the pathophysiology and current data are examined in relation to various kinds of biomarkers, such as immunological and inflammation biomarkers, coagulation and hematological biomarkers, as well as cardiac, biochemical, and other biomarkers. This review provides a comprehensive analysis of the research on the association between biomarkers and clinical characteristics, viral load, treatment efficacy, and how this knowledge might most usefully contribute to patient care.

Improving Transitions in Care for the Child with Medical Complexity Using Betty Neuman's Systems Model.

Children with medical complexity are an increasing population with frequent use of intensive care services within hospitals. As children's health improves, they are often transferred to a general unit before being discharged to home. This transition often leads to an acute decline in health, resulting in emergent interventions. Betty Neuman's systems model provides the foundation to guide prevention interventions on stress mitigation to promote stability. An evidence-based transition bundle of care may be a valuable tool to prevent stress at the time of transfer from the intensive care unit and prevent deterioration.

Hospitalization and Intensive Therapy at the End of Life.

Germany has more intensive care unit (ICU) beds per capita than the USA, but the utilization of these resources at the end of life is unknown. Retrospective observational study using nationwide German hospital discharge data (DRG statistics; DRG, diag- nosis-related groups) from 2007 to 2015. We investigated hospital deaths and use of intensive care services during terminal hospitalizations. Population-based incidences were standardized to the age and sex distribution of the German population. Standardized hospital admission rates increased by 0.8% annually (from 201.9 to 214.6 per 1000 population), while hospital admissions involving ICU care increased by 3.0% annually (from 6.5 to 8.2 per 1000 population). Among all deaths in the German population, the proportion of hospital deaths with ICU care increased by 2.3% annually (from 9.8% to 11.8%). Among all hospital deaths, the proportion involving ICU care increased by 2.8% annually from 20.6% (2007) to 25.6% (2015). In patients aged 65 and older, the use of intensive care services during terminal hospitalizations increased 3 times faster than hospital deaths. Use of intensive care services during terminal hospitalizations increased across all age groups, particularly the elderly. The increased need for end-of-life care in the ICU calls for improvements in educational, policy, and reimbursement strategies. It is unclear whether ICU care was appropriate and compliant with patient preferences.

Characteristics and outcomes of oncology patients requiring admission to an Australian intensive care unit.

e21653 Background: Patients with advanced malignancies have historically been considered poor candidates for the intensive care unit (ICU), however survival and prognosis is continually improving and requirements for use of intensive care services is increasing. This study aimed to understand the characteristics and outcomes of oncology patients admitted to an Australian ICU and identify potential prognostic factors. Methods: A single-centre, retrospective, cohort study was conducted at Royal North Shore Hospital, a tertiary public hospital in Sydney, Australia with a 58-bed quaternary ICU. All patients aged > 18 years, admitted under the medical oncology team requiring ICU admission between June 2014 and June 2016 were evaluated. Data collected included basic demographics, cancer type and status, performance status (ECOG) and co-morbidities (ACE-27 score). Clinical outcomes were determined including ICU and hospital mortality, requirements (ventilation, dialysis, vasopressors, infection) and APACHE II scores. Results: There were 96 patients admitted to the ICU during the study period. Mean age was 61 years, 58% were male and 76% had metastatic disease. Most patients were receiving palliative treatment (89%), with recent chemotherapy (43%), immunotherapy (10%) and other therapies (5%). Of the 10 patients with recent immunotherapy, three (all melanoma) required ICU admission due to immunotoxicity with all three alive at time of data collection (mean 222 days follow-up). 13% were admitted due to an oncological emergency. Most common primary tumour site was thoracic (20%), genitourinary (11%), breast (10%) and melanoma (10%). Mean APACHE II score was 17 (SD 5.33), mean SOFA score was 4 (SD 2.70), ICU mortality was 5% and hospital mortality was 22%. For the 75 patients (78%) discharged from hospital, 42 (56%) were still alive at time of data collection (mean 321 days follow-up). Conclusions: Our patient population had good short-term outcomes for survival despite most receiving palliative treatment, although prognostic scores were also favourable. This suggests cancer patients can achieve positive outcomes after ICU admission with appropriate selection of patients crucial.

Post-Acute Care Facility as a Discharge Destination for Patients in Need of Palliative Care in Brazil

Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P < .001) and mechanical ventilation (2% vs 40%, P < .001), when compared to noncancer patients. Approximately one-third of discharges from hospitals to a PACF involved a heterogeneous group of patients in need of palliative care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.

Use of Intensive Care Services for Medicare Beneficiaries Undergoing Major Surgical Procedures.

Use of intensive care after major surgical procedures and whether routinely admitting patients to intensive care units (ICUs) improve outcomes or increase costs is unknown. The authors examined frequency of admission to an ICU during the hospital stay for Medicare beneficiaries undergoing selected major surgical procedures: elective endovascular abdominal aortic aneurysm (AAA) repair, cystectomy, pancreaticoduodenectomy, esophagectomy, and elective open AAA repair. The authors compared hospital mortality, length of stay, and Medicare payments for patients receiving each procedure in hospitals admitting patients to the ICU less than 50% of the time (low use), 50 to 89% (moderate use), and 90% or greater (high use), adjusting for patient and hospital factors. The cohort ranged from 7,878 patients in 162 hospitals for esophagectomies to 69,989 patients in 866 hospitals for endovascular AAA. Overall admission to ICU ranged from 35.6% (endovascular AAA) to 71.3% (open AAA). Admission to ICU across hospitals ranged from less than 5% to 100% of patients for each surgical procedure. There was no association between hospital use of intensive care and mortality for any of the five surgical procedures. There was a consistent association between high use of intensive care with longer length of hospital stay and higher Medicare payments only for endovascular AAA. There is little consensus regarding the need for intensive care for patients undergoing major surgical procedures and no relationship between a hospital's use of intensive care and hospital mortality. There is also no consistent relationship across surgical procedures between use of intensive care and either length of hospital stay or payments for care.

Use of Intensive Care Services and Associated Hospital Mortality After Massachusetts Healthcare Reform*

To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality. Population-based cohort study. Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform. All nonpregnant nonelderly adults (age 18-64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were eligible, excluding patients who were not residents of a respective state at the time of admission. We used a difference-in-differences approach to compare trends in ICU admissions and outcomes of in-hospital mortality and discharge destination for ICU patients. Healthcare reform in Massachusetts was associated with a decrease in ICU patients without insurance from 9.3% to 5.1%. There were no significant changes in adjusted ICU admission rates, mortality, or discharge destination. In a sensitivity analysis excluding a state that enacted Medicaid reform prior to the study period, our difference-in-differences analysis demonstrated a significant increase in mortality of 0.38% per year (95% CI, 0.12-0.64%) in Massachusetts, attributable to a greater per-year decrease in mortality postreform in comparison states (-0.37%; 95% CI, -0.52% to -0.21%) compared with Massachusetts (0.01%; 95% CI, -0.20% to 0.11%). Massachusetts healthcare reform increased the number of ICU patients with insurance but was not associated with significant changes in ICU use or discharge destination among ICU patients. Reform was also not associated with changed in-hospital mortality for ICU patients; however, this association was dependent on the comparison states chosen in the analysis.

Evaluating Outcomes and Costs in Perioperative Care

Evaluating Outcomes and Costs in Perioperative Care

Is There a Starling Curve for Intensive Care?

Large differences exist in the provision of ICU beds worldwide, with a complicated mix of risks and benefits to the population of having either too few or too many beds. Having too few beds can result in delayed admission of patients to the ICU or no admission at all, with either scenario potentially increasing mortality. Potential societal benefits of having few beds include lower costs for health care and less futile intensive care at the end of life. With added ICU beds for a population, mortality benefit should accrue, but there is still the question of whether the addition of beds always means that more lives will be saved or whether there is a point at which no additional mortality benefit is gained. With an abundance of ICU beds may come the possibility of increasing harm in the forms of unnecessary costs, poor quality of deaths (ie, excessively intensive), and iatrogenic complications. The possibility of harm may be likened to the concept of falling off a Starling curve, which is traditionally used to describe worsening heart function when overfilling occurs. This commentary examines the possible implications of having too few or too many ICU beds and proposes the concept of a family of Starling curves as a way to conceptualize the balance of societal benefits and harms associated with different availability of ICU beds for a population.

Use of Intensive Care Services during Terminal Hospitalizations in England and the United States

Use of Intensive Care Services during Terminal Hospitalizations in England and the United States

Use of Intensive Care Services during Terminal Hospitalizations in England and the United States

Despite broad concern regarding the provision and cost of health care at the end of life, country-specific patterns of care have rarely been compared. To assess the use of hospital and intensive care services during terminal hospitalizations in England and the United States, two populations with similar socioeconomic backgrounds and life expectancies. Retrospective cohort study over a 1-year period (2001) using national (England) Hospital Episode Statistics, and regional (seven U.S. states) administrative discharge data as well as English and U.S. census data. We measured hospitalization rates and death rates during hospitalization with and without intensive care. Age-adjusted acute hospitalization rates were 110.5 per 1,000 population in England versus 105.3 in the seven U.S. states, with the same mortality rate (0.9 per 1,000 population) in both countries. Of all deaths, 50.3% occurred in hospital in England and 36.6% in the United States, yet only 5.1% of all deaths in England involved intensive care, versus 17.2% in the United States, representing 10.1% of hospital deaths in England versus 47.1% in the United States. Greater intensive care use in the U.S. was most notable with older age; among decedents 85+ years, intensive care was used for 31.5% of medical deaths and 61.0% of surgical deaths in the United States versus 1.9 and 8.5% of deaths in England. Despite similar overall hospitalization rates in England and the United States, there were marked differences in terminal hospitalizations, with far greater use of intensive care services in the United States, especially among medical patients and the elderly population.

Variation in Inpatient Therapy and Diagnostic Evaluation of Children with Henoch Schönlein Purpura

To describe variation regarding inpatient therapy and evaluation of children with Henoch Schönlein purpura (HSP) admitted to children's hospitals across the United States. We conducted a retrospective cohort study of children discharged with a diagnosis of HSP between 2000 and 2007 by use of inpatient administrative data from 36 children's hospitals. We examined variation among hospitals in the use of medications, diagnostic tests, and intensive care services with multivariate mixed effects logistic regression models. During the initial HSP hospitalization (n = 1988), corticosteroids were the most common medication (56% of cases), followed by opioids (36%), nonsteroidal antiinflammatory drugs (35%), and antihypertensive drugs (11%). After adjustment for patient characteristics, hospitals varied significantly in their use of corticosteroids, opioids, and nonsteroidal antiinflammatory drugs; the use of diagnostic abdominal imaging, endoscopy, laboratory testing, and renal biopsy; and the use of intensive care services. By contrast, hospitals did not differ significantly regarding administration of antihypertensive drugs or performance of skin biopsy. The significant variation identified may contribute to varying HSP clinical outcomes between hospitals, warrants further investigation, and represents a potentially important opportunity to improve quality of care.

How does lack of insurance affect use of intensive care? A population-based study*

One in six Americans aged <65 yrs are without health insurance. Although lack of insurance is associated with reduced access to many health services, the relationship between lack of insurance and use of intensive care services is unclear. We sought to compare the use of intensive care by insured and uninsured populations. Retrospective population-based cross-sectional study of five U.S. states (Florida, Massachusetts, New Jersey, New York, and Virginia), analyzing use of hospital and intensive care unit (ICU) services by all residents of these states <65 yrs of age. Data sources included the five 1999 state hospital discharge databases and the 2000 U.S. Census Bureau Current Population Survey. Nonfederal hospitals in the five states (all hospitalizations in these during 1999). None. There were 39.3 million and 7.8 million individuals aged 0-64 yrs with and without insurance, respectively, in the five-state sample. The uninsured population was far less likely to be hospitalized (odds ratio [OR], 0.458; 95% confidence interval [CI], 0.456-0.460; p < .001) and to be admitted to the ICU (OR, 0.581, 95% CI: 0.576-0.587, p < .001). Differences persisted irrespective of age, gender, ethnicity, or reason for admission. Among those hospitalized, the uninsured were more likely to receive intensive care (OR, 1.24; 95% CI, 1.22-1.25; p < .01). Hospital mortality rates for patients admitted to the ICU ranged by age from 4.0% to 6.9% for the uninsured and from 2.7% to 5.5% for the insured (OR, 1.12-1.54; p < .01). Americans without insurance use ICU services less often than those with insurance, primarily because of decreased likelihood of hospital admission in the first place. Outcome is worse for those who are admitted to the ICU, possibly because they are sicker when they seek care.

Therapeutic Intervention Scoring System

The Therapeutic Intervention Scoring System (TISS) introduced in 1974 has become a widely accepted method of classifying critically ill patients. In response to requests to update the system because of recent innovations in critical care, some items have been deleted, some have been added, and certain point scores have been adjusted. Explanations of items within the system and guidelines for the user are included. A comparison of the new 1983 system to the old 1974 system in 100 consecutive patients reveals no difference in total point scores. We hope this updated explanation will ease the task of assessing use of intensive care services.