Intensive Care Unit Utilization Research Articles

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.

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.

S673 Outcome of Patients with Upper Gastrointestinal Bleeding During the COVID-19 Pandemic

Introduction: The COVID-19 pandemic has created challenges in upper gastrointestinal bleeding (UGIB) management due to concerns regarding aerosolization during endoscopy and patient hesitancy in presenting to hospital. The impact of the pandemic on UGIB outcomes is not well described. Methods: We described adults with UGIB admitted to general medicine services or intensive care units (ICU) during the first wave of the COVID-19 pandemic (March 1–June 30 2020) at 7 hospitals in Toronto and Mississauga, Ontario. The historical control group consisted of patients admitted to these hospitals from March 1-June 30, 2018 and March 1-June 30, 2019. We compared primary (in-hospital mortality) and secondary outcomes (ICU utilization, transfusion requirements, persistent bleeding, and need for angiographic/surgical management of bleeding) using multivariable regression models, controlling for patient demographic factors, comorbidities, severity and etiology of bleeding, and admitting hospital. Results: There were 363 admissions for UGIB from March 1-June 30, 2020 (COVID-19 period) and 950 admissions from March 1-June 30 2018 and 2019 (historical control period). There were no differences between the two groups with respect to baseline variables of age, sex, underlying cirrhosis, Charlson comorbidity index, and the modified Glasgow-Blatchford and pre-endoscopy Rockall mortality risk scores (Table 1). Patients in the COVID-19 time period were less likely to undergo endoscopy (64% vs. 71%, p=0.015). There were no differences between the two groups for the primary outcome of in-hospital mortality or any secondary outcomes (Table 1). On multivariable analysis, patients admitted with UGIB during the COVID-19 time period did not have greater in-hospital mortality (odds ratio [OR]=0.72, 95% confidence interval [CI] 0.30-1.57), or any differences in ICU utilization, number of red blood cell units transfused, persistent bleeding, and angiographic/surgical management. Conclusion: Although fewer patients admitted to hospital with UGIB during the first wave of the COVID-19 pandemic received endoscopy, there was no difference in clinical outcomes.Table 1.: Comparison of Inpatient Outcomes of NVUGIB Patients.

Clinical Management of Hospitalized Coronavirus Disease 2019 Patients in the United States.

BackgroundThe objective of this study was to characterize hospitalized coronavirus disease 2019 (COVID-19) patients and describe their real-world treatment patterns and outcomes over time.MethodsAdult patients hospitalized on May 1, 2020–December 31, 2020 with a discharge diagnosis of COVID-19 were identified from the Premier Healthcare Database. Patient and hospital characteristics, treatments, baseline severity based on oxygen support, length of stay (LOS), intensive care unit (ICU) utilization, and mortality were examined.ResultsThe study included 295657 patients (847 hospitals), with median age of 66 (interquartile range, 54–77) years. Among each set of demographic comparators, the majority were male, white, and over 65. Approximately 85% had no supplemental oxygen charges (NSOc) or low-flow oxygen (LFO) at baseline, whereas 75% received no more than NSOc or LFO as maximal oxygen support at any time during hospitalization. Remdesivir (RDV) and corticosteroid treatment utilization increased over time. By December, 50% were receiving RDV and 80% were receiving corticosteroids. A higher proportion initiated COVID-19 treatments within 2 days of hospitalization in December versus May (RDV, 87% vs 40%; corticosteroids, 93% vs 62%; convalescent plasma, 68% vs 26%). There was a shift toward initiating RDV in patients on NSOc or LFO (68.0% [May] vs 83.1% [December]). Median LOS decreased over time. Overall mortality was 13.5% and it was highest for severe patients (invasive mechanical ventilation/extracorporeal membrane oxygenation [IMV/ECMO], 53.7%; high-flow oxygen/noninvasive ventilation [HFO/NIV], 32.2%; LFO, 11.7%; NSOc, 7.3%). The ICU use decreased, whereas mortality decreased for NSOc and LFO.ConclusionsClinical management of COVID-19 is rapidly evolving. This large observational study found that use of evidence-based treatments increased from May to December 2020, whereas improvement in outcomes occurred over this time-period.

Demographic profile and outcome of patients admitted to a COVID dedicated hospital in Bangladesh during the second wave.

In December 2019, with pneumonia-like clinical manifestations, a new severe acute respiratory syndrome coronavirus 2 emerged and quickly escalated into a pandemic. Since the first case detected in early March of last year, 8668 have died with an infection mortality rate of 1.52%, as of March 20, 2021. Bangladesh has been struck by the 2nd wave from mid-march 2021. As data on the second wave are sparse, the present study observed the demographic profile, symptoms, and outcomes of Coronavirus Disease 2019 (COVID-19) patients during this wave.The study was conducted at Sheikh Russel National Gastroliver Institute on 486 admitted cases during the 2nd wave of COVID-19 in Bangladesh (March 24–April 24, 2021) using a cross-sectional study design and a convenient sampling technique.Out of 486 cases, 306 (62.9%) were male, and 180 were female, with a mean age of 53.47 ± 13.86. The majority of patients (32.5%) were between the ages of 51 and 60. While fever and cough being the predominant symptoms (>70% cases), the most common co-morbidities were hypertension (41.4) and diabetes mellitus (39.4). Intensive care unit utilization rate was 25%, and a half of the patients had 51% to 70% tomographic lung involvement with an overall mortality rate of 19.3%. Older age, chronic renal disease, percentage of lung involvement, and intensive care unit necessity were important mortality determinants.The present study gives an insight into the demographic profiles and outcomes of admitted patients with COVID-19 during the second wave at a covid dedicated hospital in Bangladesh.

Analysis of the Effects of COVID-19 Mask Mandates on Hospital Resource Consumption and Mortality at the County Level.

Coronavirus disease 2019 (COVID-19) threatens vulnerable patient populations, resulting in immense pressures at the local, regional, national, and international levels to contain the virus. Laboratory-based studies demonstrate that masks may offer benefit in reducing the spread of droplet-based illnesses, but few data are available to assess mask effects via executive order on a population basis. We assess the effects of a county-wide mask order on per-population mortality, intensive care unit (ICU) utilization, and ventilator utilization in Bexar County, Texas. We used publicly reported county-level data to perform a mixed-methods before-and-after analysis along with other sources of public data for analyses of covariance. We used a least-squares regression analysis to adjust for confounders. A Texas state-level mask order was issued on July 3, 2020, followed by a Bexar County-level order on July 15, 2020. We defined the control period as June 2 to July 2 and the postmask order period as July 8, 2020-August 12, 2020, with a 5-day gap to account for the median incubation period for cases; longer periods of 7 and 10 days were used for hospitalization and ICU admission/death, respectively. Data are reported on a per-100,000 population basis using respective US Census Bureau-reported populations. From June 2, 2020 through August 12, 2020, there were 40,771 reported cases of COVID-19 within Bexar County, with 470 total deaths. The average number of new cases per day within the county was 565.4 (95% confidence interval [CI] 394.6-736.2). The average number of positive hospitalized patients was 754.1 (95% CI 657.2-851.0), in the ICU was 273.1 (95% CI 238.2-308.0), and on a ventilator was 170.5 (95% CI 146.4-194.6). The average deaths per day was 6.5 (95% CI 4.4-8.6). All of the measured outcomes were higher on average in the postmask period as were covariables included in the adjusted model. When adjusting for traffic activity, total statewide caseload, public health complaints, and mean temperature, the daily caseload, hospital bed occupancy, ICU bed occupancy, ventilator occupancy, and daily mortality remained higher in the postmask period. There was no reduction in per-population daily mortality, hospital bed, ICU bed, or ventilator occupancy of COVID-19-positive patients attributable to the implementation of a mask-wearing mandate.

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...

Enhanced Recovery After Surgery Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection.

BackgroundEnhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol.MethodsElectronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre- and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach.ResultsA total of 64 pre- and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p < 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p < 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p < 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005).ConclusionsImplementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00268-021-06259-1.

Role of pharmacist during COVID-19 pandemic: A retrospective study focused on critically ill COVID-19 patients

Background and aimDuring the Coronavirus 2019 (COVID-19) crisis, there has been a huge demand for medications and unprecedented utilization of intensive care unit (ICU) services that subsequently and profoundly impacted the quality of medical care provided to COVID-19 patients. This study aimed to shed light on the role of pharmacists on the health care provided to critically ill COVID-19 patients. MethodsA retrospective study, was conducted in Diriyah hospital in Riyadh, Saudi Arabia on all COVID-19 patients admitted to the ICU between June 27th and August 15th, 2020 until patients were transferred to the medical ward, discharged, or deceased. All medication related interventions performed by pharmacists have been documented electronically, collected and subsequently categorized and analyzed. ResultsThe mean age of patients was 58.8 years (±12.98 SD), with age of >64 years in approximately 37%. Four hundred and seventy interventions (470) were made by pharmacists of which 32%, 11.7%, 4%, 2.6%, 2.1% were due to error in dosing regimens, drug duplication, missing drug information, drugs requiring prior authorization, and missing critical information, respectively; while 40.6% were due to medication shortage of which 40.3% were substituted with alternative medications. Based on the analysis of drugs involved in interventions, medication groups that were mainly associated with interventions included antibiotics (16.8%), electrolytes/minerals (11.7%) and vitamins (9.4%). ConclusionDuring health crises such as COVID-19 pandemic, the role of pharmacists in the ICU services becomes extremely crucial for providing better patients’ outcomes. Further studies should be conducted to follow up these findings in the context of COVID-19 pandemic.

Effect of a urine culture stewardship initiative on urine culture utilization and catheter-associated urinary tract infections in intensive care units.

Urine cultures have poor specificity for catheter-associated urinary tract infections (CAUTIs). We evaluated the effect of a urine-culture stewardship program on urine culture utilization and CAUTI in adult intensive care units (ICUs). A quasi-interventional study was performed from 2015 to 2017. The study cohort comprised 21,367 patients admitted to the ICU at a teaching hospital. The urine culture stewardship program included monthly 1-hour discussions with ICU house staff emphasizing avoidance of "pan-culture" for sepsis workup and obtaining urine culture only if a urinary source of sepsis is suspected. The urine culture utilization rate metric (UCUR; ie, no. urine cultueres/catheter days ×100) was utilized to measure the effect. Monthly UCUR, catheter utilization ratio (CUR), and CAUTI rate were reported on an interactive quality dashboard. To ensure safety, catheterized ICU patients (2015-2016) were evaluated for 30-day readmission for UTI. Time-series data and relationships were analyzed using Spearman correlation coefficients and regression analysis. Urine culture utilization decreased from 3,081 in 2015 to 2,158 in 2016 to 1,218 in 2017. CAUTIs decreased from 78 in 2015 to 60 in 2016 and 28 in 2017. Regression analysis over time showed significant decreases in UCUR (r, 0.917; P < .0001) and CAUTI rate (r, 0.657; P < .0001). The co-correlation between UCUR and CAUTI rate was (r, 0.625; P < .0001) compared to CUR and CAUTI rate (r, 0.523; P = .004). None of these patients was readmitted with a CAUTI. Urine culture stewardship program was effective and safe in reducing UC overutilization and was correlated with a decrease in CAUTIs. Addition of urine-culture stewardship to standard best practices could reduce CAUTI in ICUs.