Intensive Care Unit Utilization Research Articles

Burden of illness in patients with pulmonary hypertension due to interstitial lung disease: a real-world analysis

BackgroundPulmonary hypertension due to interstitial lung disease (PH-ILD) is associated with high rates of respiratory failure and death. Healthcare resource utilization (HCRU) and cost data are needed to characterize PH-ILD disease burden.MethodsA retrospective cohort analysis of the Truven Health MarketScan® Commercial Claims and Encounters Database and Medicare Supplemental Database between June 2015 to June 2019 was conducted. Patients with ILD were identified and indexed based on their first claim with a PH diagnosis. Patients were required to be 18 years of age on the index date and continuously enrolled for 12-months pre- and post-index. Patients were excluded for having a PH diagnosis prior to ILD diagnosis or the presence of other non-ILD, PH-associated conditions. Treatment patterns, HCRU, and healthcare costs were compared between the 12 months pre- versus 12 months post-index date.ResultsIn total, 122 patients with PH-ILD were included (mean [SD] age, 63.7 [16.6] years; female, 64.8%). The same medication classes were most frequently used both pre- and post-index (corticosteroids: pre-index 43.4%, post-index 53.5%; calcium channel blockers: 25.4%, 36.9%; oxygen: 12.3%, 25.4%). All-cause hospitalizations increased 2-fold, with 29.5% of patients hospitalized pre-index vs. 59.0% post-index (P < 0.0001). Intensive care unit (ICU) utilization increased from 6.6 to 17.2% (P = 0.0433). Mean inpatient visits increased from 0.5 (SD, 0.9) to 1.1 (1.3) (P < 0.0001); length of stay (days) increased from 5.4 (5.9) to 7.5 (11.6) (P < 0.0001); bed days from 2.5 (6.6) to 8.0 (16.3) (P < 0.0001); ICU days from 3.8 (2.3) to 7.0 (13.2) (P = 0.0362); and outpatient visits from 24.5 (16.8) to 32.9 (21.8) (P < 0.0001). Mean (SD) total all-cause healthcare costs increased from $43,201 ($98,604) pre-index to $108,387 ($190,673) post-index (P < 0.0001); this was largely driven by hospitalizations (which increased from a mean [SD] of $13,133 [$28,752] to $63,218 [$75,639] [P < 0.0001]) and outpatient costs ($16,150 [$75,639] to $25,604 [$93,964] [P < 0.0001]).ConclusionPH-ILD contributes to a high HCRU and cost burden. Timely identification, management, and treatment are needed to mitigate the clinical and economic consequences of PH-ILD development and progression.

A Machine Learning Decision Support Tool Optimizes Whole Genome Sequencing Utilization in a Neonatal Intensive Care Unit.

The Mendelian Phenotype Search Engine (MPSE), a clinical decision support tool using Natural Language Processing and Machine Learning, helped neonatologists expedite decisions to whole genome sequencing (WGS) to diagnose patients in the Neonatal Intensive Care Unit. After the MPSE was introduced, utilization of WGS increased, time to ordering WGS decreased, and WGS diagnostic yield increased.

A two-tiered high-flow nasal cannula approach does not increase intensive care utilization and hospital length of stay in bronchiolitis.

The use of HFNC according to a two-tiered approach does not appear to be associated with an increase in ICU utilization or LOS. • Bronchiolitis is one of the most common reasons for hospitalization in infants. • Use high-flow nasal canulae oxygen (HFNC) has rapidly spread outside the intensive care unit (ICU) to treat infants with bronchiolitis, although increasing evidence has dampened the initial enthusiasm about their effectiveness. • Concerns nowadays are rising about HFNC overuse and associated increased use of hospital resources, including escalation of care to ICU. • A more selective use of HFNC according to a "two-tiered approach", intended as a second-line rescue treatment in non-severely ill children who fail standard oxygen therapy, is not associated with increased ICU and length ofhospital stay.

COPD comorbidity and checkpoint inhibitor pneumonitis in a case-control study of patients with lung cancer.

e14700 Background: Checkpoint inhibitor pneumonitis (CIP) is the most common high-grade immune-related adverse event among patients with lung cancer. Risk factors for CIP include interstitial lung disease, fibrosis on pre-treatment CT imaging, and likely COPD. This study aims to compare COPD variables and CIP outcomes between cases of high and low-grade CIP, and controls without CIP. We hypothesized that the presence and severity of COPD would affect the evaluation, management, and outcomes of CIP. Methods: From a database of patients with lung cancer who received at least one dose of an immune checkpoint inhibitor between 2/1/11 and 4/7/22 at a comprehensive cancer center, we identified all CIP cases and randomly selected a larger number of controls without CIP. The study team reviewed routine clinical documentation and collected data on pre-treatment respiratory function (e.g., comorbidities, spirometry) and CIP outcomes (e.g., diagnostic testing, interventions, severity). Low-grade (grades 1-2) versus high-grade (grades 3-5) CIP were defined by the Common Terminology Criteria for Adverse Events. We tested categorical variables using Chi-squared or Fisher’s exact test depending on assumptions. We compared continuous variables using the Wilcoxon rank sum or the Kruskall-Wallis test. The database was maintained on a secure, cloud-based REDCap database, validated with data quality rules, and with IRB approval. Results: This study compared 84 cases of CIP (including high-grade CIP in 48/84 cases, 57%) with 252 controls. COPD was a commonly documented comorbidity in both groups (60% cases, 53% controls, p 0.28), although not all patients had spirometry (44% cases, 40% controls). Among the cases, CIP diagnosis occurred at a median of 3 months; at that time, 29% of cases were using a scheduled daily inhaled corticosteroid, and 18% continued to smoke tobacco. Between high-grade and low-grade CIP, there was similar COPD prevalence (64% vs. 56%, p 0.51), severity by forced expiratory volume in one second (FEV1) as a predicted percentage (64 ± 21% vs. 62 ± 16%, p 0.81), and diffusing capacity of the lungs for carbon monoxide as a predicted percentage (62 ± 19% vs. 61 ± 18%, p 0.82). In terms of CIP outcomes, COPD was not associated with the incidence of hospitalization (26/46, 57%, p 0.76), length of hospitalization (8.4 vs. 7.8 days, p=0.33), intensive care unit utilization (10/21, 48%, p 0.52), or death (5/9, 56%, p 0.94). Cardiac evaluation appeared slightly different among patients with COPD (e.g., more often ordered echo; less often ordered BNP or diuresis), although CIP management was overall similar. Conclusions: The presence or severity of pre-treatment COPD was not associated with differences in the management or outcomes of CIP when it occurred. The cardiac evaluation of CIP may have been different because COPD can decrease the specificity of BNP and be less responsive to diuretics.

The Role of Delirium on Short- and Long-Term Postoperative Outcomes Following Major Gastrointestinal Surgery for Cancer.

The growing burden of an aging population has raised concerns about demands on healthcare systems and resources, particularly in the context of surgical and cancer care. Delirium can affect treatment outcomes and patient recovery. We sought to determine the prevalence of postoperative delirium among patients undergoing digestive tract surgery for malignant indications and to analyze the role of delirium on surgical outcomes. Medicare claims data were queried to identify patients diagnosed with esophageal, gastric, hepatobiliary, pancreatic, and colorectal cancers between 2018 and 2021. Postoperative delirium, occurring within 30 days of operation, was identified via International Classification of Diseases, 10th edition codes. Clinical outcomes of interested included "ideal" textbook outcome (TO), characterized as the absence of complications, an extended hospital stay, readmission within 90 days, or mortality within 90 days. Discharge disposition, intensive care unit (ICU) utilization, and expenditures also were examined. Among 115,654 cancer patients (esophageal: n = 1854, 1.6%; gastric: n = 4690, 4.1%; hepatobiliary: n = 6873, 5.9%; pancreatic: n = 8912, 7.7%; colorectal: n = 93,325, 90.7%), 2831 (2.4%) were diagnosed with delirium within 30 days after surgery. On multivariable analysis, patients with delirium were less likely to achieve TO (OR 0.27 [95% CI 0.25-0.30]). In particular, patients who experienced delirium had higher odds of complications (OR 3.00 [2.76-3.25]), prolonged length of stay (OR 3.46 [3.18-3.76]), 90-day readmission (OR 1.96 [1.81-2.12]), and 90-day mortality (OR 2.78 [2.51-3.08]). Furthermore, patients with delirium had higher ICU utilization (OR 2.85 [2.62-3.11]). Upon discharge, patients with delirium had a decreased likelihood of being sent home (OR 0.40 [0.36-0.46]) and instead were more likely to be transferred to a skilled nursing facility (OR 2.17 [1.94-2.44]). Due to increased utilization of hospital resources, patients with delirium incurred in-hospital expenditures that were 55.4% higher (no delirium: $16,284 vs. delirium: $28,742) and 90-day expenditures that were 100.7% higher (no delirium: $2564 vs. delirium: $8226) (both p < 0.001). Notably, 3-year postoperative survival was adversely affected by delirium (no delirium: 55.5% vs. delirium: 37.3%), even after adjusting risk for confounding factors (HR 1.79 [1.70-1.90]; p < 0.001). Postoperative delirium occurred in one in 50 patients undergoing surgical resection of a digestive tract cancer. Delirium was linked to a reduced likelihood of achieving an optimal postoperative outcome, increased ICU utilization, higher expenditures, and a worse long-term prognosis. Initiatives to prevent delirium are vital to improve postoperative outcomes among cancer surgery patients.

Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation.

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted,sent to the intensive care unit (ICU), and sent to the operating room (OR). Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentageof TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

A Path to High-Value Gastric Cancer Surgery Care Delivery.

To evaluate the feasibility, safety, and effectiveness of a comprehensive regional program, including the Minimally Invasive Recovery and Empowerment Care (MIREC) pathway, that can significantly reduce hospital stays after laparoscopic gastrectomy without increasing adverse events. Cost-effectiveness and improving patient outcomes are crucial in providing quality gastric cancer care worldwide. To compare the outcomes of gastric cancer surgery using 2 different models of care within an integrated healthcare system from February 2012 to March 2023. The primary endpoint was the length of hospital stay. The secondary endpoints were the need for intensive care unit care, emergency room (ER) visits, readmission, reoperation, and death within 30 days after surgery. There were 553 patients, 167 in the pre-(February 2012-April 2016) and 386 in the post-MIREC period (May 2016-March 2023). Perioperative chemotherapy utilization increased from 31.7% to 76.4% (P < 0.0001). Laparoscopic gastrectomy increased from 17.4% to 97.7% (P < 0.0001). Length of hospitalization decreased from 7 to 2 days (P < 0.0001), with 32.1% and 88% of patients discharged home on postoperative day 1 and postoperative day 2, respectively. When comparing pre- and post-MIREC, intensive care unit utilization (10.8% vs. 2.9%, P < 0.0001), ER visits (34.7% vs. 19.7%, P = 0.0002), and readmission (18.6% vs. 11.1%, P = 0.019) at 30 days were also considerably lower. In addition, more patients received postoperative adjuvant chemotherapy (31.4% to 63.5%, P < 0.0001), and the time between gastrectomy and starting adjuvant chemotherapy was also less (49-41 days; P = 0.002). This comprehensive regional program, which encompasses regionalization care, laparoscopic approach, modern oncologic care, surgical subspecialization, and the MIREC pathway, can potentially improve gastric cancer surgery outcomes. These benefits include reduced hospital stays and lower complication rates. As such, this program can revolutionize how gastric cancer surgery is delivered, leading to a higher quality of care and increased value to patients.

Nationwide trends in intensive care unit utilization in the elective endovascular treatment of unruptured intracranial aneurysms.

Multiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs. This is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed. Among 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges. Most patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.

Opportunity for Reduction of Intensive Care Unit Resource Utilization in Pediatric Blunt Liver and Spleen Injuries: A National Trauma Data Bank Analysis

IntroductionGuidelines for blunt liver and spleen injury (BLSI) by the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) emphasize hemodynamic stability over injury grade when considering non-operative management (NOM). In this study, we examined rates of intensive care unit (ICU) admission for children with isolated low-risk BLSI among US hospitals. MethodsThe National Trauma Data Bank (NTDB) was queried for patients ages 1-15 admitted between 2017 and 2019 with BLSI. Patients with penetrating injuries and/or concomitant non-abdominal injuries with AIS score ≥3 were excluded. Isolated BLSI was considered low-risk if the patient had normal admission vitals and did not require operative intervention. Primary outcomes measured were ICU admission, ICU length of stay (LOS), and overall LOS. Results5777 patients ages 15 and under presented with isolated BLSI during the study period. 2031/5777 (35.2%) were considered low-risk. Low-risk patients had lower rates of ICU admission compared to high-risk patients (30.9% vs. 41.6%, p < 0.001) and had shorter ICU LOS (median 2 days vs. 2, p < 0.001) and shorter overall LOS (median 41 h vs. 54, p < 0.001). Pediatric verified and non-pediatric verified trauma centers had similar rates of ICU admission (36.8% vs. 38.9%, p = 0.11). ConclusionFurther work is needed to capture opportunities for reduction in ICU utilization in isolated BLSI. Level of EvidenceIII

Hospital-Level NICU Capacity, Utilization, and 30-Day Outcomes in Texas

Risk-adjusted neonatal intensive care unit (NICU) utilization and outcomes vary markedly across regions and hospitals. The causes of this variation are poorly understood. To assess the association of hospital-level NICU bed capacity with utilization and outcomes in newborn cohorts with differing levels of health risk. This population-based retrospective cohort study included all Medicaid-insured live births in Texas from 2010 to 2014 using linked vital records and maternal and newborn claims data. Participants were Medicaid-insured singleton live births (LBs) with birth weights of at least 400 g and gestational ages between 22 and 44 weeks. Newborns were grouped into 3 cohorts: very low birth weight (VLBW; <1500 g), late preterm (LPT; 34-36 weeks' gestation), and nonpreterm newborns (NPT; ≥37 weeks' gestation). Data analysis was conducted from January 2022 to October 2023. Hospital NICU capacity measured as reported NICU beds/100 LBs, adjusted (ie, allocated) for transfers. NICU admissions and special care days; inpatient mortality and 30-day postdischarge adverse events (ie, mortality, emergency department visit, admission, observation stay). The overall cohort of 874 280 single LBs included 9938 VLBW (5054 [50.9%] female; mean [SD] birth weight, 1028.9 [289.6] g; mean [SD] gestational age, 27.6 [2.6] wk), 63 160 LPT (33 684 [53.3%] female; mean [SD] birth weight, 2664.0 [409.4] g; mean [SD] gestational age, 35.4 [0.8] wk), and 801 182 NPT (407 977 [50.9%] female; mean [SD] birth weight, 3318.7 [383.4] g; mean [SD] gestational age, 38.9 [1.0] wk) LBs. Median (IQR) NICU capacity was 0.84 (0.57-1.30) allocated beds/100 LB/year. For VLBW newborns, NICU capacity was not associated with the risk of NICU admission or number of special care days. For LPT newborns, birth in hospitals with the highest compared with the lowest category of capacity was associated with a 17% higher risk of NICU admission (adjusted risk ratio [aRR], 1.17; 95% CI, 1.01-1.33). For NPT newborns, risk of NICU admission was 55% higher (aRR, 1.55; 95% CI, 1.22-1.97) in the highest- vs the lowest-capacity hospitals. The number of special care days for LPT and NPT newborns was 21% (aRR, 1.21; 95% CI,1.08-1.36) and 37% (aRR, 1.37; 95% CI, 1.08-1.74) higher in the highest vs lowest capacity hospitals, respectively. Among LPT and NPT newborns, NICU capacity was associated with higher inpatient mortality and 30-day postdischarge adverse events. In this cohort study of Medicaid-insured newborns in Texas, greater hospital NICU bed supply was associated with increased NICU utilization in newborns born LPT and NPT. Higher capacity was not associated with lower risk of adverse events. These findings raise important questions about how the NICU is used for newborns with lower risk.

Introduction of a Post-Anaesthesia Care Unit in a Teaching Hospital Is Associated with a Reduced Length of Hospital Stay in Noncardiac Surgery: A Single-Centre Interrupted Time Series Analysis.

A post-anaesthesia care unit (PACU) may improve postoperative care compared with intermediate care units (IMCU) due to its dedication to operative care and an individualized duration of postoperative stay. The effects of transition from IMCU to PACU for postoperative care following intermediate to high-risk noncardiac surgery on length of hospital stay, intensive care unit (ICU) utilization, and postoperative complications were investigated. This single-centre interrupted time series analysis included patients undergoing eleven different noncardiac surgical procedures associated with frequent postoperative admissions to an IMCU or PACU between January 2018 and March 2019 (IMCU episode) and between October 2019 and December 2020 (PACU episode). Primary outcome was hospital length of stay, secondary outcomes included postoperative complications and ICU admissions. In total, 3300 patients were included. The hospital length of stay was lower following PACU admission compared to IMCU admission (IMCU 7.2 days [4.2-12.0] vs. PACU 6.0 days [3.6-9.1]; p < 0.001). Segmented regression analysis demonstrated that the introduction of the PACU was associated with a decrease in hospital length of stay (GMR 0.77 [95% CI 0.66-0.91]; p = 0.002). No differences between episodes were detected in the number of postoperative complications or postoperative ICU admissions. The introduction of a PACU for postoperative care of patients undergoing intermediate to high-risk noncardiac surgery was associated with a reduction in the length of stay at the hospital, without increasing postoperative complications.

Retracted: Drug Utilization Pattern of Antibiotics in Neonatal intensive care unit in a Tertiary Care Hospital, India

Article retractedMillions of babies are admitted to neonatal intensive care units worldwide, with a significant proportion facing various indications. Given that sepsis is a leading cause of mortality and morbidity among infants globally, including in India, the importance of efficient antibiotic use cannot be overstated. As the global problem of drug resistance intensifies, prudent antibiotic usage becomes crucial in mitigating treatment failures and ensuring the survival of newborns. Aim: to evaluate the pattern of antimicrobial drug utilization in neonatal intensive care unit (NICU) to assess the criteria for drug selection in tertiary care hospital.Materials and Methods. It was an observational prospective study conducted for six months in which 200 neonates admitted to neonatal intensive care unit at tertiary care Hospital, were included. Demographic details, duration of hospital stay, reason for admission (disease pattern), various drugs prescribed were noted. Results. Out of 200 neonates the number of male babies admitted to neonatal intensive care unit were 115 (57.5%) and female babies were 85 (42.5%). Many of the neonates were from age group of 1 to 5 (58.5%) days. Most of the neonates were from weight group of 2.5 to 3 (26.5%) kg. Majority of neonates hospital admission duration was 3 to 6 days is 98 (49%) neonates. Most common disorder requiring neonatal intensive care unit admission was Preterm with Respiratory Distress Syndrome (29%) followed by Neonatal Sepsis (19.5%) and Preterm (11%). Other distress reported include birth asphyxia (16 neonates or 8%), Neonatal convulsions (12 neonates or 6%), Late preterm (13 neonates or 6.5%), Hypernatremia (9 neonates or 4.5%), Meconium Aspiration Syndrome (3 neonates or 1.5%), Neonatal Hypoglycemia (5 neonates or 2.5%) and others (23 neonates or 11.5%). Among 423 antibiotics most prescribed antibiotic was Inj. Piperacillin + Tazobactam (35.4%) followed by Gentamycin (30.2%). Out of 423 drugs 152 are fixed dose combination and single drugs are 271 in this study in which piperacillin + tazobactam of fixed dose combination and gentamicin dose combination and single drugs are 271 in this study in which piperacillin + tazobactam of fixed dose combination and gentamicin of single drug had prescribed in more amount.Conclusion. The findings of this study will contribute to the existing body of knowledge regarding the appropriate use of antibiotics in the NICU, thereby providing insights for healthcare professionals to make informed decisions regarding antibiotic therapy. Empirical antibiotics were administered to every newborn based on their individual conditions. The antibiotic utilization pattern within this study group was determined to be rational.

Temporal trends in critical care utilization and outcomes in allogeneic hematopoietic stem cell transplant recipients.

Historically, the prognosis of allogeneic hematopoietic stem cell transplant (allo-HCT) recipients who require intensive care unit (ICU) admission has been poor. We aimed to describe the epidemiological trends of ICU utilization and outcomes in allo-HCT patients. We conducted a retrospective cohort study including adults (≥ 18) undergoing allo-HCT between 01/01/2005 and 31/12/2020 at Mayo Clinic, Rochester. Temporal trends in outcomes were assessed by robust linear regression modelling. Risk factors for hospital mortality were chosen a priori and assessed with multivariable logistic regression modelling. Of 1,249 subjects, there were 486 ICU admissions among 287 individuals. Although older patients underwent allo-HCT (1.64 [95% CI: 1.11 to 2.45] years per year; P = 0.025), there was no change in ICU utilization over time (P = 0.91). The ICU and hospital mortality rates were 19.2% (55/287) and 28.2% (81/287), respectively. There was a decline in ICU mortality (-0.38% [95% CI: -0.70 to -0.06%] per year; P = 0.035). The 1-year post-HCT mortality for those requiring ICU admission was 56.1% (161/287), with no significant difference over time, versus 15.8% (141/891, 71 missing) among those who did not. The frequency and duration of invasive mechanical ventilation (IMV) declined. In multivariable analyses, higher serum lactate, higher sequential organ failure assessment (SOFA) scores, acute respiratory distress (ARDS), and need for IMV were associated with greater odds of hospital mortality. Over time, rates of ICU utilization have remained stable, despite increasing patient age. Several trends suggest improvement in outcomes, notably lower ICU mortality and frequency of IMV. However, long-term survival remains unchanged. Further work is needed to improve long-term outcomes in this population.

Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit.

We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.

Development and implementation of an Enhanced Recovery After Cranial Surgery pathway following supratentorial tumor resection at a tertiary care center.

Controlling length of stay (LOS) reduces rates of nosocomial infections and falls, facilitates earlier return to daily activities, and decreases strain on the healthcare system. Complications following supratentorial tumor resection present early in the postoperative period, thereby enhancing the prospect of safe, early discharge. Here, the authors describe their initial experience with the development and implementation of an Enhanced Recovery After Cranial Surgery (ERACS) pathway following resection of supratentorial tumors in select patients. This was a nonrandomized, ambispective quality improvement study of patients undergoing elective craniotomy for supratentorial tumor resection at New York University Langone Health between November 17, 2020, and May 19, 2022. Eligible patients were prospectively enrolled in either the ERACS pathway or the standard pathway. These prospective cohorts were compared to a retrospective cohort of patients who met eligibility criteria for the pathway. Patients in the ERACS pathway cohort were targeted for discharge on postoperative day 2. The primary outcome metric was hospital LOS. Secondary outcome metrics included duration of intensive care unit (ICU) care and rates of 30-day emergency department visits, readmissions, and complications. Over the study period, 188 of 317 patients (59.3%) who underwent supratentorial tumor resection met inclusion criteria for ERACS pathway enrollment. Sixty-three patients were enrolled in the ERACS pathway, and 125 patients completed the standard pathway. The historical cohort consisted of 332 patients who would have been eligible for ERACS enrollment. Patients in the ERACS pathway cohort had a median LOS of 1.93 days compared with 2.92 and 2.88 days for patients in the standard pathway and historical cohort, respectively (p < 0.001). There was a significant reduction in ICU utilization in ERACS pathway patients (16.0 ± 6.53 vs 29.5 ± 53.0 vs 21.8 ± 18.2 hours, p = 0.005). There were no differences in the rates of 30-day emergency department visits (12.7% vs 9.6% vs 10.9%, p = 0.809) and readmissions (4.8% vs 4.0% vs 7.8%, p = 0.279) between groups. Patients in the ERACS pathway cohort experienced reduced LOS and ICU utilization, with similar rates of adverse outcomes compared to standard pathway patients. The authors' initial experience suggests that an accelerated recovery pathway can be safely implemented following supratentorial tumor resection in select patients.

Real World Experience with a Zuma -1 Cohort 4 Adopted Approach to CRS and Icans in CAR-T Recipients

Introduction: Axicabtagene ciloleucel (axi-cel) is a chimeric antigen receptor T-cell (CAR-T) therapy approved for treatment of relapsed/refractory (R/R) large B cell lymphoma (LBCL). The registrational phase I/II ZUMA-1 study Cohorts 1 and 4 addressed toxicity management in terms of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) whereby tocilizumab and corticosteroids were deployed earlier in Cohort 4.(1,2) Although Cohort 4 consisted of only 41 patients, it demonstrated that earlier intervention resulted in significantly fewer cases of grade ≥3 CRS (2%) and ICANS (17%) and a lower cumulative dose of steroids. Furthermore, efficacy as determined by overall response rate (ORR) and complete response (CR) did not appear to be negatively impacted by earlier use of tocilizumab and corticosteroids. However, given the small number of patients in Cohort 4, concern has remained that earlier intervention may have a deleterious impact on CAR-T cell expansion, persistence, and efficacy. During the COVID-19 pandemic, with overwhelmed Intensive Care Units (ICUs) across the country, we adopted a Cohort 4 guided approach to CAR-T toxicity management with the hope of decreasing the need for ICU level of care following CAR-T infusion. Herein, we present our single-institution, real-world experience since implementing an early intervention strategy with Cohort 4 and compare it with our previous Cohort 1 axi-cel recipients in terms of toxicity (CRS, ICANS, ICU utilization) and efficacy. Methods: 119 patients receiving axi-cel CAR-T therapy for R/R LBCL are included in this single-institution, retrospective study with 70 in Cohort 1 and 49 in Cohort 4. The transition from a Cohort 1 to Cohort 4 approach occurred in March 2021. Thus, for Cohort 1 the data cut-off was February 2021 and for Cohort 4 it was after April 2021. The COVID pandemic and the lack of the ICU capacity was the initial chief rationale for transitioning to Cohort 4. This study was conducted following IRB approval and in accordance with the Declaration of Helsinki. R version 1.3.1099 (R-studio) was used for all statistical modeling. All statistical tests were 2-sided and conducted at the 0.05 level of significance. Results: The median age was 62 (22-88) years-old, 35% female gender, 76% advanced stage III-IV disease, 22% with bulky ≥10cm disease, 71% with diagnosis of Diffuse LBCL, and 26% with more than three lines of previous therapy. The median follow-up time at analysis was 1.5 years. Laboratory parameters and comorbidities did not significantly differ between groups except for a higher incidence of renal insufficiency in the Cohort 4 group (28.6% vs 4.3%, p&amp;lt;0.001) (see Table 1). The median maximum grade CRS was significantly lower for Cohort 4 (2 vs 1, p&amp;lt;0.001) although the median grade of ICANS was not different. The utilization of tocilizumab and siltuximab was similar in both groups. The duration of steroid use was comparable in both; however, the total steroid use (dexamethasone equivalent) was notably lower in Cohort 4 (110 mg vs 190 mg, p=0.026). ICU admission following CAR-T infusion was much lower in Cohort 4 (16.3% vs 60%, p&amp;lt;0.001). Most patients (&amp;gt;80%) were discharged home after CAR-T therapy and did not need placement in a rehabilitation center or long-term facility. The ORR and ongoing responses were similar in both groups with nearly 90% achieving a response and 60% with an ongoing response. The cumulative incidence of relapse, PFS, and OS were not significantly different between the groups (see Figure 1). Conclusion: The use of an early toxicity intervention strategy based upon ZUMA-1 Cohort 4 in the real world results in significantly lower high-grade CRS, decreased cumulative steroid dose, and an 73% reduction in ICU utilization without significantly impacting efficacy in terms of incidence of relapse, PFS, or OS. Our real-world experience with the adoption of a Cohort 4 strategy suggests that patient morbidity may be greatly attenuated without compromising CAR-T therapy response. However, the need for longer follow-up to evaluate the impact early use of steroids has on CAR-T persistence and PFS at &amp;gt;5 years remains.

Predictors of inpatient outcomes of COVID-19 infection in patients with cirrhosis in the early pandemic phase: A nationwide survey.

Previous studies conducted at single centers have suggested that patients with cirrhosis are at a greater risk for worse outcomes with COVID-19. However, there is limited data on a national level in the United States. We aimed to study hospital-related outcomes and identify the predictors of poor outcomes in patients with cirrhosis and concurrent COVID-19. We queried 2020 National Inpatient and Readmission databases to identify all hospitalizations due to cirrhosis in adults with a diagnosis of COVID-19. Primary outcomes included inpatient mortality, mechanical ventilation (MV), and intensive care unit (ICU) utilization. Secondary outcomes included mean length of stay (LOS) and mean hospitalization costs. We classified cirrhosis into compensated (CC) and decompensated (DC) groups. We identified 25194 hospitalizations of adult patients due to cirrhosis with a concurrent diagnosis of COVID-19. These patients had higher mortality (19.50% vs 6.19%, P ≤ 0.01), MV (11.7% vs 2.8%, P ≤ 0.01), ICU utilization (17.3% vs 8.1%, P ≤ 0.01), LOS (8.89 days vs 6.16 days, P ≤ 0.01), and total hospitalization costs ($24 817 vs $18 505, P ≤ 0.01) than those without COVID-19. On subgroup analysis, patients in the DC group had higher mortality, LOS, and hospitalization costs compared to those in the CC group. On multivariate analysis, we also found that COVID-19 infection, age, Charlson Comorbidity Index ≥3, acute kidney injury, end-stage renal disease, septic shock, acute respiratory failure, MV, and ICU status were independent predictors for mortality. Our study suggests that COVID-19 infection is an independent predictor of mortality in patients with cirrhosis, with threefold higher mortality and increased resource utilization. Early intervention through immunizations and advanced COVID-19 therapies can help improve these outcomes.

Abstract 18801: Impact of COVID-19 Pandemic on Cardiovascular Diseases Hospitalisation, Management and Mortality in Brazil

Introduction: The COVID-19 pandemic led to a reduction in cardiovascular (CVD) hospital admissions in many countries. We aimed to assess the effect of the COVID-19 pandemic on CVD hospitalizations, management, and mortality in Brazil. Methods: Hospitalization data for the years 2020 and 2021 for Brazil and regions were analyzed using the Datasus hospital admission system. We analyzed the number of hospitalizations, the number and proportion of intensive care unit (ICU) utilization, and the number and proportion of in-hospital deaths. The observed data were compared to the average of the previous three years (2017 to 2019). Absolute differences and risk ratios (RR) were calculated, with the RR obtained by dividing the observed values by the expected ones for each period studied. Results: There was a reduction in CVD hospital admissions, with 184,727 (95% CI 157,579 to 211,876) fewer hospitalizations than expected, representing a decrease of 16.2% (RR 0.838; 95% CI 0.836-0.839). There were two valleys of reduction in CVD hospitalizations, the first before the first peak of Covid-19 hospitalizations and the second simultaneous to the second peak of Covid-19 hospitalizations in 2021. There was a 9% decrease in the absolute number of CVD admissions in the ICU (RR 0.910; 95% CI 0.907-0.912), associated with a 4.7% absolute decrease in the number of CVD admissions that resulted in in-hospital deaths (RR 0.953; 95% CI 0.949-0.957). However, there was an 8.6% increase in the proportion of ICU admissions due to CVD (RR 1.086; 95% CI 1.084-1.088) and a significant increase of 14.4% in the proportion of admissions due to CVD that resulted in in-hospital death. Conclusions: Brazil′s data reveal that the Covid-19 pandemic reduced the number of CVD hospitalizations, but with a higher proportion of ICU use and higher in-hospital mortality.

Cost-utility analysis and cross-country comparison of pharmacogenomics-guided treatment in colorectal cancer patients participating in the U-PGx PREPARE study

ObjectivesA cost-utility analysis was conducted to evaluate pharmacogenomic (PGx)-guided treatment compared to the standard-of-care intervention among patients diagnosed with colorectal cancer (CRC) in Italy. MethodsData derived from a prospective, open-label, block randomized clinical trial, as a part of the largest PGx study worldwide (355 patients in both arms) were used. Mortality was used as the primary health outcome to estimate life years (LYs) gained in treatment arms within a survival analysis context. PGx-guided treatment was based on established drug-gene interactions between capecitabine, 5-fluorouracil and irinotecan with DPYD and/or UGT1A1 genomic variants. Utility values for the calculation of Quality Adjusted Life Year (QALY) was based on Visual Analog Scale (VAS) score. Missing data were imputed via the Multiple Imputation method and linear interpolation, when possible, while censored cost data were corrected via the Replace-From-The-Right algorithm. The Incremental Cost-Effectiveness Ratio (ICER) was calculated for QALYs. Raw data were bootstrapped 5000 times in order to produce 95% Confidence Intervals based on non-parametric percentile method and to construct a cost-effectiveness acceptability curve. Cost differences for study groups were investigated via a generalized linear regression model analysis. Total therapy cost per patient reflected all resources expended in the management of any adverse events, including medications, diagnostics tests, devices, surgeries, the utilization of intensive care units, and wards. ResultsThe total cost of the study arm was estimated at €380 (∼ US$416; 95%CI: 195–596) compared to €565 (∼ US$655; 95%CI: 340–724) of control arm while the mean survival in study arm was estimated at 1.58 (+0.25) LYs vs 1.50 (+0.26) (Log Rank test, X2 = 4.219, df=1, p-value=0.04). No statistically significant difference was found in QALYs. ICER was estimated at €13418 (∼ US$14695) per QALY, while the acceptability curve indicated that when the willingness-to-pay was under €5000 (∼ US$5476), the probability of PGx being cost-effective overcame 70%. The most frequent adverse drug event in both groups was neutropenia of severity grade 3 and 4, accounting for 82.6% of total events in the study arm and 65.0% in the control arm. Apart from study arm, smoking status, Body-Mass-Index and Cumulative Actionability were also significant predictors of total cost. Subgroup analysis conducted in actionable patients (7.9% of total patients) indicated that PGx-guided treatment was a dominant option over its comparator with a probability greater than 92%. In addition, a critical literature review was conducted, and these findings are in line with those reported in other European countries. ConclusionPGx-guided treatment strategy may represent a cost-saving option compared to the existing conventional therapeutic approach for colorectal cancer patient management in the National Health Service of Italy.

Reducing Overutilization of High-flow Nasal Cannula in Children with Bronchiolitis.

Bronchiolitis is a leading cause of pediatric hospitalizations. A high-flow nasal cannula (HFNC) does not significantly improve clinical outcomes and is associated with increased costs and intensive care unit (ICU) utilization. Despite this, hospitals continue to overuse HFNC in children with bronchiolitis. We aimed to reduce HFNC initiation in children hospitalized with bronchiolitis by 20 percentage points within 6 months. This study included patients aged 1 month to 2 years diagnosed with bronchiolitis, excluding patients with prematurity less than 32 weeks or preexisting cardiopulmonary, genetic, congenital, or neuromuscular abnormalities. Measures included HFNC utilization, length of stay, length of oxygen supplementation (LOOS), ICU transfers, and emergency department (ED) revisits and readmissions. For our primary intervention, we implemented a HFNC initiation protocol incorporating a respiratory scoring system, a multidisciplinary care-team huddle, and an emphasis on supportive care. Staff education, electronic health record integration, and audit and feedback were used to support implementation. Statistical process control charts were used to track metrics. We analyzed 325 hospitalizations (126 baseline and 199 postintervention). The proportion of children hospitalized with bronchiolitis who received HFNC decreased from a mean of 82% to 60% within 1 month of implementation. Length of stay decreased from a median of 54 to 42 hours, and length of oxygen supplementation decreased from 50 to 38 hours. There were no significant changes in ICU transfers, 7-day ED revisits, or readmissions. Implementing a HFNC initiation protocol can safely reduce the overutilization of HFNC in children hospitalized with bronchiolitis.