Intensive Care Unit Utilization Research Articles

Mortality of adolescents with isolated traumatic brain injury does not vary with type of level I trauma center.

Pediatric patients with isolated severe traumatic brain injury (TBI) treated at pediatric trauma centers (PTCs) have lower mortality than those treated at adult trauma centers (ATCs) or mixed trauma centers (MTCs). The primary objective of this study was to determine if adolescent patients (15-17 years) with isolated severe TBI also benefited from treatment at PTCs. This was a cross-sectional analysis using a national sample of adolescent trauma patients obtained from the American College of Surgeons' Trauma Quality Program Participant Use Files for 2013 to 2017 (n = 3,524). Mortality, the primary outcome variable, was compared between Level I PTCs, ATCs, and MTCs using multiple logistic regression controlling for patient characteristics and injury severity. Secondary outcomes included discharge disposition, utilization of craniotomy, intensive care unit (ICU) utilization, ICU length of stay (LOS), and hospital LOS. Prior to adjustment, patients treated at ATCs (odds ratio [OR], 2.76; p = 0.032) and MTCs (OR, 2.36; p = 0.070) appeared to be at greater risk of mortality than those treated at PTCs. However, after adjustment, this difference disappeared (ATC OR, 1.21; p = 0.733; MTC OR, 0.95; p = 0.919). Patients treated at ATCs and MTCs were more severely injured than those treated at PTCs and more likely to be admitted to an ICU (ATC OR, 2.12; p < 0.001; MTC OR, 1.91; p < 0.001). No other secondary outcome differed between center types. Adolescent patients with isolated severe TBI treated at ATCs and MTCs had similar mortality risk as those treated at PTCs. The difference in injury severity across center types warrants additional research. Prognostic/Epidemiological; Level III.

Decreased hospital length of stay and intensive care unit admissions for non-COVID blunt trauma patients during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic overwhelmed hospitals, forcing adjustments including discharging patients earlier and limiting intensive care unit (ICU) utilization. This study aimed to evaluate ICU admissions and length of stay (LOS) for blunt trauma patients (BTPs). MethodsA retrospective review of COVID (3/19/20-6/30/20) versus pre-COVID (3/19/19-6/30/19) BTPs at eleven trauma centers was performed. Multivariable analysis was used to identify risk factors for ICU admission. Results12,744 BTPs were included (6942 pre-COVID vs. 5802 COVID). The COVID cohort had decreased mean LOS (3.9 vs. 4.4 days, p = 0.029), ICU LOS (0.9 vs. 1.1 days, p < 0.001), and rate of ICU admission (22.3% vs. 24.9%, p = 0.001) with no increase in complications or mortality compared to the pre-COVID cohort (all p > 0.05). On multivariable analysis, the COVID period was associated with decreased risk of ICU admission (OR = 0.82, CI 0.75–0.90, p < 0.001). ConclusionsBTPs had decreased LOS and associated risk of ICU admission during COVID, with no corresponding increase in complications or mortality.

Cardiovascular Mortality During the COVID-19 Pandemics in a Large Brazilian City: A Comprehensive Analysis.

Introduction:The impact of COVID-19 pandemics on cardiovascular diseases (CVD) may be caused by health system reorganization and/or collapse, or from changes in the behaviour of individuals. In Brazil, municipalities were empowered to define regulatory measures, potentially resulting in diverse effects on CVD morbimortality.Objective:To analyse the impact of COVID-19 pandemics on CVD outcomes in Belo Horizonte (BH), the sixth greater capital city in Brazil, including: mortality, mortality at home, hospitalizations, intensive care unit utilization, and in-hospital mortality; and the differential effect according to sex, age range, social vulnerability, and pandemic’s phase.Methods:Ecological study analysing data from the Mortality and Hospital Information System of BH residents aged ≥30 years. CVD was defined as in Chapter IX from ICD-10. Social vulnerability was classified by a composite socioeconomic index as high, medium and low. The observed age-standardized rates for epidemiological weeks 10–48, 2020, were compared to the expected rates (mean of 2015–2019). Risk ratios (RiR) were analysed and 95% confidence intervals were calculated for all estimates. Population projected to 2020 for BH and its census tracts were used to calculate rates.Results:We found no changes in CVD mortality rates (RiR 1.01, 95%CI 0.96–1.06). However, CVD deaths occurred more at homes (RiR 1.32, 95%CI 1.20–1.46) than in hospitals (RiR 0.89, 95%CI 0.79–0.99), as a result of a substantial decline in hospitalization rates, even though proportional in-hospital deaths increased. The rise in home deaths was greater in older adults and in had an increasing gradient in those more socially vulnerable (RiR 1.45); for high (RiR 1.45), medium (RiR 1.32) and low vulnerability (RiR 1.21).Conclusion:The greater occurrence of CVD deaths at home, in parallel with lower hospitalization rates, suggests that CVD care was disrupted during the COVID-19 pandemics, which more adversely affected older and more socially vulnerable individuals, exacerbating health inequities in BH.

Severe maternal morbidity: admission shift from intensive care unit to obstetric high-dependency unit

BackgroundTo study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU).MethodsThis is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend.ResultsA total of 40,412 women delivered and 447 (1.11%) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 1.59% in 2016 and then dropped to 0.67% in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P < 0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P < 0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac diseases (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). The establishment of HDU led to 20% reduction in ICU admission, which was mainly related to obstetric indications.ConclusionsThe introduction of HDU helps to reduce ICU utilization in obstetric population.

Burden of illness in carbapenem-resistant Acinetobacter baumannii infections in US hospitals between 2014 and 2019

BackgroundCarbapenem-resistant (CR) Acinetobacter baumannii is a concerning pathogen in the USA and worldwide.MethodsTo assess the comparative burden of CR vs carbapenem-susceptible (CS) A. baumannii, this retrospective cohort study analyzed data from adult patients in 250 US hospitals from the Premier HealthCare Database (2014–2019). The outcomes analyzed included hospital length of stay (LOS), intensive care unit (ICU) utilization, discharge status, in-hospital mortality, readmission rates and hospital charges. Logistic regression was used for univariate and multivariable assessment of the independent relationship between relevant covariates, with a focus on CR status, and in-hospital mortality.Results2047 Patients with CR and 3476 patients with CS A. baumannii infections were included. CR A. baumannii was more commonly isolated in respiratory tract infections (CR 40.7% and CS 27.0%, P < 0.01), whereas CS A. baumannii was more frequently associated with bloodstream infections (CS 16.7% and CR 8.6%, P < 0.01). Patients with CR A. baumannii infections had higher in-hospital (CR 16.4% vs CS 10.0%; P < 0.01) and 30-day (CR 32.2% vs CS 21.6%; P < 0.01) mortality compared to those with CS infections. After adjusting for age, sex, admission source, infection site, comorbidities, and treatment with in vitro active antibiotics within 72 h, carbapenem resistance was independently associated with increased mortality (adjusted odds ratio 1.42 [95% confidence interval 1.15; 1.75], P < 0.01). CR infections were also associated with increases in hospital length of stay (CR 11 days vs CS 9 days; P < 0.01), rate of intensive care unit utilization (CR 62.3% vs CS 45.1%; P < 0.01), rate of readmission with A. baumannii infections (CR 17.8% vs CS 4.0%; P < 0.01) and hospital charges.ConclusionsThese data suggest that the burden of illness is significantly greater for patients with CR A. baumannii infections and are at higher risk of mortality compared with CS infections in US hospitals.

Age Adjusted Comorbidity Risk Index Does Not Predict Outcomes in an Autologous Hematopoietic Stem Cell Transplant Population

The hematopoietic comorbidity risk index (HCT-CI) is a pre-transplant risk assessment tool used to prognosticate morbidity and mortality of patients undergoing allogeneic hematopoietic stem cell transplantation. Recently, the HCT-CI was updated to include an age component (HCT-CI-age). Although other studies have validated this tool in allogeneic stem cell transplant recipients, it has never been studied in an autologous transplant patient population. We retrospectively reviewed 181 patients who underwent their first autologous hematopoietic stem cell transplant. We aimed (1) to assess whether an HCT-CI score of 3 or greater is associated with greater mean transplant hospital days, greater total hospital days, or greater risk of intensive care unit (ICU) utilization and (2) whether age influences any of these responses independent of HCT-CI. There were 136 patients with an HCT-CI score of 3 or higher and 45 with a score less than 3. The length of initial transplant hospitalization in days was not statistically significant (15.6 v 16.4 days, P = 0.38). Utilizing spline modeling prediction curves, transplant hospital days were estimated to increase from a mean of 15.5 days for a patient with 4 comorbidities to a mean of 22.7 days for a patient with 8 comorbidities. Age made no significant impact on any of the outcomes. The HCT-CI, with or without age, in an autologous stem cell transplantation did not predict length of hospitalization or utilization of the ICU. Patients with higher-HCT-CI scores at baseline may incrementally utilize more resources, and this should be explored in a larger cohort population.

Intensive Care Unit Utilization Following Major Surgery and the Nurse Work Environment.

Across hospitals, there is wide variation in ICU utilization after surgery. However, it is unknown whether and to what extent the nurse work environment is associated with a patient's odds of admission to an intensive care unit. To estimate the relationship between hospitals' nurse work environment and a patient's likelihood of ICU admission and mortality following surgery. A cross-sectional study of 269 764 adult surgical patients in 453 hospitals was conducted. Logistic regression models were used to estimate the effects of the work environment on the odds of patients' admission to the intensive care unit and mortality. Patients in hospitals with good work environments had 16% lower odds of intensive care unit admission and 15% lower odds of mortality or intensive care unit admission than patients in hospitals with mixed or poor environments. Patients in hospitals with better nurse work environments were less likely to be admitted to an intensive care unit and less likely to die. Hospitals with better nurse work environments may be better equipped to provide postoperative patient care on lower acuity units.

753. Impact of COVID-19 on Healthcare Facility-Onset Clostridiodes difficile Infection

BackgroundIt is estimated that the majority of hospitalized COVID-19 patients around the world received antibiotics despite the fact that bacterial co-infections are rare. This can lead to increased antimicrobial resistance and Clostridioides difficile infections (CDI). Gastrointestinal symptoms of COVID-19 may also contribute to increased testing. The objective of this study was to assess the impact of the COVID-19 pandemic on our healthcare facility-onset (HO) CDI rates.MethodsThis was a retrospective cross-sectional study comparing CDI rate per 1,000 patient days, C. diff order rate per 1,000 patient days, Standardized Antimicrobial Administration Ratio (SAAR), and Standardized Infection Ratio (SIR) in the pre-COVID-19 period from January 1, 2019 to December 31, 2019 to the COVID-19 period from April 1, 2020 to March 31, 2021 at a 877-bed tertiary care hospital in Detroit, Michigan. CDI and order rates were extracted from the electronic medical record (Epic™ Bugsy). SAAR and SIR data were extracted from National Healthcare Safety Network (NHSN).ResultsThe average CDI rate per 1,000 patient days was 4.29 pre-COVID-19 compared to 1.98 during COVID-19 with a 54% reduction, and the C. diff order rate per 1,000 patient days also decreased from 130.89 to 93.03, resulting in a 29% reduction (Figure 1). The SIR was 0.383 compared to 0.308 during COVID-19 (P-value 0.404). SAAR decreased from 1.095 to 0.945 (P-value < 0.001). However, our institution experienced three COVID-19 waves, with peaks in April 2020, November 2020 and March 2021, that correlated with high risk CDI antibiotic utilization in intensive care unit (ICU) (Figure 2). The average hand hygiene rate increased from 82% to 92%. Figure 1. Clostridioides difficile order and infection rates pre-and during COVID-19 pandemic. Figure 2. Standardized Antimicrobial Administration Ratio (SAAR) pre-and during COVID-19 pandemic.ConclusionDespite the COVID-19 pandemic, the HO-CDI and C. diff order rates and overall SAAR decreased; however, antibiotic utilization increased in the ICU during the COVID-19 waves. The overall decrease may be multifactorial and related to increased hand hygiene compliance, isolation and personal protective equipment use and overall decreased antibiotic use and C. diff orders.Disclosures Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

1136. Effect of Weekly Antibiotic Rounds as a Core Strategy of the Antimicrobial Stewardship Program on Antibiotic Utilization in a Terciary-care Neonatal Intensive Care Unit, Medellin, Colombia

BackgroundAntibiotics are among the most prescribed drugs in the neonatal intensive care unit (NICU), but frequently are used inappropriately exposing preterm neonates to additional harm. Antibiotic stewardship programs (ASP) have demonstrated impact on antibiotic use in the hospital setting, but implementation in neonatal units is challenging. We sought to determine the effects of weekly antibiotic rounds on overall antibiotic consumption in the NICU. MethodsSingle-center, retrospective observational study. In November 2014, we implemented weekly antibiotic rounds in a 60-bed tertiary-care NICU, led by a pediatric infectious disease physician. Antibiotic therapy decisions were made in collaboration with neonatologists. Data collected included the proportion of patients receiving antibiotics, irrespective of the indication. Multimodal ASP was implemented hospital-wide in 2015. Antibiotic consumption was measured with days of therapy (DOT). Data on costs and in-hospital mortality were obtained from pharmacy and hospital records. ResultsFrom November 2014 to December 2020, we evaluated 13609 neonates admitted to the NICU during rounds. Of those, 3607 (27%) were receiving at least one antibiotic. Overall, the proportion of patients with antibiotics decreased from 31% to 19% during the study period (p< 0.001). In 2017, an outbreak of neonatal necrotizing enterocolitis (NEC) occurred. Specific countermeasures as well as reinforcement of ASP were implemented. Despite Antibiotic usage by DOT increased in 2017 driven by empiric treatment with piperacillin tazobactam in patients with NEC, overall antibiotic consumption decreased from 254.4 DOT/1000 patient days (PD) to 162.4 DOT/1000 PD (Figure 1). Annual costs from antibiotic prescriptions were US&23,161 in 2015 and decreased to US&12.046 in 2020 saving over US&3,800/year (fig 2a). During the study period, we did not observe an increase in crude in-hospital mortality rate (Figure 2b). Primary Y axis indicates the proportion of patients with at least one antibiotic prescription during rounds. Secondary Y axis indicates antibiotic consumption by days of therapy metrics.Antibiotic prescription costs and NICU mortality rates during study period A. Annual antibiotic prescription costs; B. NICU mortality rateConclusionWeekly antibiotic rounds led to a significant decrease in antibiotic utilization in our NICU. This strategy is relatively simple and low-cost, saves hospital resources and has a large impact on antibiotic use. Hence, its implementation is encouraged as part of successful antimicrobial stewardship programs. Disclosures All Authors: No reported disclosures

Clinicodemographic profile, intensive care unit utilization and mortality rate among COVID-19 patients admitted during the second wave in Bangladesh

IntroductionThe second wave of COVID-19 arrived in Bangladesh in March 2021. This pilot research from a tertiary care COVID-dedicated hospital observed the clinicodemographic profile, intensive care unit (ICU) utilization, and mortality rate among COVID-19 patients admitted during the second wave. MethodsReverse transcription-polymerase chain reaction or chest high-resolution computed tomography confirmed 972 COVID-19 cases included in this cross-sectional study from 24 March to 23 June 2021, recruited using convenience sampling. Data regarding clinicodemographic profile, ICU utilization and mortality rate were analyzed. ResultsThe mean study cohort age was 54.47±12.73 years, with most patients (48.3%) aged 41−60; 64.1% were men. Fever (77.9%) and cough (75.9%) were the most common symptoms, and hypertension (43.6%) and diabetes (42.15%) the most common comorbidities. Nearly half of patients had total lung involvement of 26%−50%, and 23.8% required ICU. Overall mortality was 16.5%, whereas the mortality rate among ICU admitted patients was 56.1%. The most important predictors of mortality were older age, chronic renal illness, the proportion of lung involvement and ICU requirement. ConclusionsWe found higher mortality and ICU utilization rate and greater total lung involvement during the second wave. The mortality rate among the elderly and ICU patients was also higher than earlier.

An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown. A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019. We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed. For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes.

Impact of Early Palliative Care on End-of-Life Outcomes in Hematologic Malignancies.

Background: Patients with hematologic malignancies (HMs) receive more disease directed care at the end of life (EOL) and often die in the hospital. The impact of early palliative care (PC) consultation on EOL quality outcomes in HMs has not been well described. Objectives: In 2017 we embedded a PC specialist within our inpatient malignant hematology team at our hospital in Providence, Rhode Island to facilitate the use of early PC. We sought to determine if this practice was accompanied by a shift in EOL outcomes. Design/Setting: We conducted a retrospective review of patients diagnosed with acute myeloid leukemia (AML) at our institution in the two years before (Cohort A) and after (Cohort B) insertion of a PC specialist. We identified patients who received a PC consultation and whether it was early or late. We then examined EOL quality outcomes: hospitalizations and intensive care unit (ICU) admissions in the last 30 days of life, chemotherapy use in the last 14 days of life, use of hospice, and death out of hospital. Results: Among 139 AML patients, 46 in Cohort A and 93 in Cohort B, we identified 34 and 47 decedents in each cohort, respectively. There was no significant improvement in EOL outcomes between Cohort A and B or among patients receiving early PC (p > 0.05); however, PC in general across all cohorts was associated with significant increase in hospice use and fewer ICU admissions (p = 0.016 and 0.0043, respectively). Conclusion: Earlier PC consultation in AML was not significantly associated with improvement in EOL quality outcomes; however, PC use in general was with improvement in use of hospice and ICU utilization. Further studies are needed to more definitively examine the relationship between early PC and EOL outcomes in patients with HMs and to examine non EOL outcomes such as patient experience and quality-of-life measures.

Evolution in Resource Utilization for Unique Toxicities Related to Chimeric Antigen Receptor T Cell Therapy from 2017 to 2020: A Database Review

Introduction:Chimeric antigen receptor T cell therapy (CAR-T) is a novel treatment that utilizes T cells by augmenting them using vector viruses to add antigens to target cancer cells. In 2017, FDA approved CD-19 CAR-T for relapsed/refractory diffuse large B-cell lymphoma and acute lymphoblastic leukemia patients ≤ 26yr old. Unique toxicities associated with CAR-T therapy include cytokine release syndrome (CRS) and immune effector cell-related neurotoxicity (ICANS). Lower-grade CRS and ICANS are managed with tocilizumab, an interleukin-6 antagonist, and steroids. Management of higher-grade CRS and ICANS requires intensive care unit (ICU) admission. Our understanding and management of CRS and ICANS continue to evolve. In this analysis, we conducted a retrospective review using the Vizient database® to investigate toxicity incidence and resource utilization among patients admitted for CAR-T therapy between 2017 and 2020.Methods:We used The Vizient® CDB database to analyze admissions for CAR-T infusion for patients over 18 years of age receiving FDA approved CD19 CAR-T axicabtagene ciloleucel (axi-cel) and tisangenlecleucel (tisa-cel) between 2017 to 2020. We compared patients who received CAR-T between October 2017 and March 2018 (group 1) to those who received CAR-T therapy between October 2019 and March 2020 (group 2). Due to the lack of diagnosis code for CRS or ICANS until 2021, surrogates billing codes such as fever, sepsis, dyspnea were used for CRS. In regards to ICANS, we used codes for febrile seizure, febrile convulsions, altered mental status, somnolence, and stupor. In addition, other adverse events such as weakness and nausea were also collected.Results:Eighty-one institutions had performed CAR-T in the period 2017 through 2020. The 2017-2018 period (group 1) included 215 patients, with a median age of 59 (49-68) years, while the CAR-T recipients in 2019-2020 (group 2) had 655 patients with a median age of 62 (52-69) years. Tisa-cel and Axi-cel was administered to 31% (n= 67) and 69% (n= 148) in group 1 and 26% (182) and 74% (n= 517) of group 2 patients respectively. The incidence of sepsis in group 1 was 18% vs. 13% in group 2, with an absolute difference of -5.8% (P value=0.04). Fever and dyspnea were the most common presentations of CRS present in 44.2% and 49% in group 1 and 35% and 28% in group 2, respectively. The incidence of fever decreased by 8.2% (p=0.02) in group 2 compared to group 1. The incidence of hypoxia was 24.7% vs. 20.5%, and the incidence of hypotension was 32.1% and 33.8% in groups 1 and 2, with no statistically significant difference between the two groups (p=0.64 and 0.19). The incidence of neurotoxicity decreased slightly in group 2 compared to group 1, but it was not statistically significant (P= 2723). Overall ICU utilization was 24.7 and 24.6% in both groups (p=0.9). The 30 days mortality in groups 1 and 2 was 6% vs. 3.7%. Tocilizumab utilization decreased by 20%, and dexamethasone or equivalent steroid usage decreased by 70% in group 2 compared to group 1. (Table 1)Conclusions:The incidence of CRS and ICANS among recipients of CAR-T remains high, with up to one-fourth of the patients requiring ICU, which has remained static. However, the general use of tocilizumab and steroids has decreased by 20% and 70%, respectively, possibly due to the implementation of consensus grading and operation protocols that may have increased awareness and judicious early interventions. [Display omitted] DisclosuresMahmoudjafari: Incyte: Membership on an entity's Board of Directors or advisory committees; Omeros: Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees.

Ethnic Disparities in AL Amyloidosis Outcomes Among Hospitalized Patients in the United States

INTRODUCTIONHealth disparities in immunoglobulin light chain (AL) amyloidosis have not been well described. We aimed to assess if health disparities between non-Hispanic (NH)-Whites, NH-Blacks and Hispanics exist and to describe differences between different ethnic/racial groups.METHODSWe conducted a retrospective cross-sectional analysis of in-patient AL amyloidosis hospitalizations from 2016 to 2018 using the Nationwide Inpatient Sample (NIS), a database which provides nationally representative information on hospitalizations in the U.S. The studied period was chosen to capture data from the ICD-10-CM codes to avoid misclassification of AL amyloidosis which was grouped with other cases of ATTR amyloidosis in the ICD-9-CM coding system. All hospitalizations in adults (age ≥18 years) were included. The exposure for the study was the occurrence of AL amyloidosis in the discharge records. Outcomes were [1] in-hospital death [2] chemotherapy use; [3] intensive care unit (ICU) utilization; [4] palliative care consultation. The analysis for this study was performed using R program version 3.5.1; a 5% type I error rate for all hypothesis tests (two-sided) was assumed.RESULTSAdmissions related to AL amyloidosis constituted 0.03% of all hospitalizations in the study period (25,470 of 90,869,381). The prevalence of AL amyloidosis related hospitalizations was higher in NH-Blacks when compared with NH-Whites (42.8 vs.28.1 per 100,000 hospitalizations). AL amyloidosis related in-hospital mortality rate was higher in NH-Whites and Hispanics when compared to NH-Blacks (6.6%% and 6.2% vs. 4.9%). In-hospital mortality with AL amyloidosis was higher in older patients, males and those who self-paid for their treatment. Utilization of ICU care was more common in NH-Blacks when compared to NH-Whites (6% vs. 4.8%). Hispanics had the lowest inpatient chemotherapy use (1.7% vs. 2.9%). Multivariable adjusted association between race/ethnicity and various outcomes showed a trend towards lower in-hospital mortality in NH-Blacks when compared to NH-Whites (OR: 0.76, 95% CI: 0.55-1.05, p=0.09) and lower utilization of palliative care services in NH-Blacks when compared with NH-Whites (OR: 0.61, 95% CI: 0.42-0.88, p=0.01). Despite very low numbers of transplant related admissions, such admissions occurred only in NH-Whites.CONCLUSIONSOur findings highlight disparities in AL amyloidosis care for NH-Blacks and Hispanics. NH-Blacks tend to have lower in-hospital mortality with higher utilization of ICU care, nevertheless, they receive the lowest palliative care services. Despite the higher utilization of ICU care, data suggest possible superior outcomes of AL amyloidosis in NH-Blacks when compared to NH-Whites. DisclosuresNo relevant conflicts of interest to declare.

The Use of Oral Amino-Bisphosphonates and Coronavirus Disease 2019 (COVID-19) Outcomes.

ABSTRACTThe determinants of the susceptibility to severe acute respiratory syndrome‐coronavirus‐2 (SARS‐CoV‐2) infection and severe coronavirus disease 2019 (COVID‐19) manifestations are yet not fully understood. Amino‐bisphosphonates (N‐BPs) have anti‐inflammatory properties and have been shown to reduce the incidence of lower respiratory infections, cardiovascular events, and cancer. We conducted a population‐based retrospective observational cohort study with the primary objective of determining if oral N‐BPs treatment can play a role in the susceptibility to development of severe COVID‐19. Administrative International Classification of Diseases, Ninth Revision, Clinical ModificationI (ICD‐9‐CM) and anatomical‐therapeutic chemical (ATC) code data, representative of Italian population (9% sample of the overall population), were analyzed. Oral N‐BPs (mainly alendronate and risedronate) were included in the analysis, zoledronic acid was excluded because of the low number of patients at risk. Incidence of COVID‐19 hospitalization was 12.32 (95% confidence interval [CI], 9.61–15.04) and 11.55 (95% CI, 8.91–14.20), of intensive care unit (ICU) utilization because of COVID‐19 was 1.25 (95% CI, 0.38–2.11) and 1.42 (95% CI, 0.49–2.36), and of all‐cause death was 4.06 (95% CI, 2.50–5.61) and 3.96 (95% CI, 2.41–5.51) for oral N‐BPs users and nonusers, respectively. Sensitivity analyses that excluded patients with prevalent vertebral or hip fragility fractures and without concomitant glucocorticoid treatment yielded similar results. In conclusion, we found that the incidence of COVID‐19 hospitalization, intensive care unit (ICU) utilization, and COVID‐19 potentially related mortality were similar in N‐BPs–treated and nontreated subjects. Similar results were found in N‐BPs versus other anti‐osteoporotic drugs. We provide real‐life data on the safety of oral N‐BPs in terms of severe COVID‐19 risk on a population‐based cohort. Our results do not support the hypothesis that oral N‐BPs can prevent COVID‐19 infection and/or severe COVID‐19; however, they do not seem to increase the risk. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Association of Healthcare Access With Intensive Care Unit Utilization and Mortality in Patients of Hispanic Ethnicity Hospitalized With COVID-19.

Racial and ethnic minority groups in the United States experience a disproportionate burden of COVID-19 deaths. To evaluate whether outcome differences between Hispanic and non-Hispanic COVID-19 hospitalized patients exist and, if so, to identify the main malleable contributing factors. Retrospective, cross-sectional, observational study of 6097 adult COVID-19 patients hospitalized within a single large healthcare system from March to November 2020. Self-reported ethnicity and primary language. Clinical outcomes included intensive care unit (ICU) utilization and in-hospital death. We used age-adjusted odds ratios (OR) and multivariable analysis to evaluate the associations between ethnicity/language groups and outcomes. 32.1% of patients were Hispanic, 38.6% of whom reported a non-English primary language. Hispanic patients were less likely to be insured, have a primary care provider, and have accessed the healthcare system prior to the COVID-19 admission. After adjusting for age, Hispanic inpatients experienced higher ICU utilization (non-English-speaking: OR, 1.75; 95% CI, 1.47-2.08; English-speaking: OR, 1.13; 95% CI, 0.95-1.33) and higher mortality (non-English-speaking: OR, 1.43; 95% CI, 1.10-1.86; English-speaking: OR, 1.53; 95% CI, 1.19-1.98) compared to non-Hispanic inpatients. There were no observed treatment disparities among ethnic groups. After adjusting for age, Hispanic inpatients had elevated disease severity at admission (non-English-speaking: OR, 2.27; 95% CI, 1.89-2.72; English-speaking: OR, 1.33; 95% CI, 1.10- 1.61). In multivariable analysis, the associations between ethnicity/language and clinical outcomes decreased after considering baseline disease severity (P < .001). The associations between ethnicity and clinical outcomes can be explained by elevated disease severity at admission and limited access to healthcare for Hispanic patients, especially non-English-speaking Hispanics.

Reducing ICU Utilization, Length of Stay, and Cost by Optimizing the Clinical Use of Continuous Monitoring System Technology in the Hospital

BackgroundContinuous monitoring system technology (CMST) aids in earlier detection of deterioration of hospitalized patients, but whether improved outcomes are sustainable is unknown. MethodsThis interrupted time series evaluation explored whether optimized clinical use of CMST was associated with sustained improvement in intensive care unit (ICU) utilization, hospital length of stay, cardiac arrest rates, code blue events, mortality, and cost across multiple adult acute care units. ResultsA total of 20,320 patients in the postoptimized use cohort compared with 16,781 patients in the preoptimized use cohort had a significantly reduced ICU transfer rate (1.73% vs 2.25%, P = .026) corresponding to 367.11 ICU days saved over a 2-year period, generating an estimated cost savings of more than $2.3 million. Among patients who transferred to the ICU, hospital length of stay was decreased (8.37 vs 9.64 days, P = .004). Cardiac arrest, code blue, and mortality rates did not differ significantly. ConclusionOpportunities exist to promote optimized adoption and use of CMST at acute care facilities to sustainably improve clinical outcomes and reduce cost.

Bariatric surgery and total knee/hip arthroplasty: an analysis of the impact of sequence and timing on outcomes

BackgroundPatients with morbid obesity may require both bariatric surgery and total knee/hip arthroplasty (TKA/THA). How to sequence these two procedures with better outcomes remains largely unstudied.MethodsThis cohort study extracted claims...

The impact of COVID 19 on heart failure hospitalization and management from an Asian perspective

Abstract Introduction COVID 19 is a global pandemic that has stretched healthcare resources. We explored the shift in patient demographics and clinical management of systolic heart failure (HF) patients during the COVID 19 outbreak. Purpose To examine the impact of COVID 19 on the hospitalization rates of decompensated systolic HF patients in a tertiary hospital in Asia and delineate differences in the clinical characteristics and management of these patients. Methods Data was extracted from the admission registry for systolic HF patients admitted to the tertiary hospital from January to June 2019 (pre-COVID) and the corresponding time period in 2020 during the COVID outbreak. We compared the demographics, clinical management and outcomes of these patients. Results There was a significant reduction in patients admitted for systolic HF during the COVID period, 174 (6.3%) compared to 240 (8.5%) pre-COVID (p=0.001). The baseline demographics were similar except for the age of patients admitted during the COVID 19 period, which were younger at 66.1±13.5 compared to 69.9±13.9 pre-COVID (p=0.007). The mean left ventricular ejection fraction (LVEF) was lower during the COVID period (22.9±10.1% vs 24.9±10.1%; p=0.032). More patients during the COVID period were placed on mineralocorticoid receptor antagonists (p=0.001) and SGLT2 inhibitors (p&amp;lt;0.001). For those with recurrent admission for systolic HF, the number for HF admissions in the preceding one year was lower during COVID period compared to pre-COVID (0.2±0.5 vs 0.5±1.0 readmissions, p&amp;lt;0.001). There was no COVID 19 infection among those admitted for systolic HF. The 30-day all-cause mortality and readmission rates were comparable between both groups. Cardiac related mortalities were higher during the COVID 19 period compared to the pre-COVID period (77.8% vs 100.0%, p=1.000). No difference was observed in the length of stay nor proportion of patients who required a higher level of care in high dependency or intensive care unit during the COVID outbreak. Those who were admitted during the COVID period were more likely first presentation of decompensated systolic HF, 119 (68.4%) compared to 135 (56.3%) pre-COVID (p=0.014). Conclusion Similar to the existing publications, there was a reduction in patients admitted for HF during the COVID period. However, for those who were admitted, these patients were younger and had lower LVEF. Most of them were first diagnosed with systolic HF during the hospitalizations. For those who had previous history of systolic HF, they had a lower number of HF admissions in the preceding one year compared to those who were admitted during the pre-COVID period. There was no difference in the 30-day mortality and utilization of high dependency or intensive care unit during the COVID outbreak. Funding Acknowledgement Type of funding sources: None.

Implications of intensive care unit admissions among medicare beneficiaries following resection of pancreatic cancer.

Intensive care unit (ICU) use has increased among patients with cancer. We sought to define factors associated with ICU admissions among patients with pancreatic cancer and characterize trends in mortality among hospital survivors. The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was used to identify patients with pancreatic cancer who underwent resection. Multivariable analyses were conducted to identify factors associated with ICU admission and mortality among hospital survivors. Among 6422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2386 (37.1%) had an ICU admission. Patients with ICU admissions were more likely to be younger (10-year increase odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.77-0.89), male (OR: 1.17, 95% CI 1.05-1.30) and undergo resection at a teaching hospital (OR: 1.19, 95% CI: 1.05-1.36). While the majority of patients survived to hospital discharge (n = 2106; 88.3%), a majority of patients (n = 1296; 54.3%) died within 6 months. Among patients who had subsequent ICU admissions, 1- and 5-year survival was only 31.8% and 11.0%, respectively. Over one-third of patients with pancreatic cancer had an ICU admission. While most patients survived hospitalization, more than one-half of patients died within 6 months of discharge and two-thirds died within 1 year. These data should serve to guide patient-provider discussions around prognosis relative to ICU utilization.