Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36:2787-2793. [PMID: 18766102 DOI: 10.1097/ccm.0b013e318186aec8]

Characteristics, interventions, and longer term outcomes of COVID-19 ICU patients in Denmark-A nationwide, observational study

BACKGROUND

Most data on intensive care unit (ICU) patients with COVID-19 originate in selected populations from stressed healthcare systems with shorter term follow-up. We present characteristics, interventions and longer term outcomes of the entire, unselected cohort of all ICU patients with COVID-19 in Denmark where the ICU capacity was not exceeded.

METHODS

We identified all patients with SARS-CoV-2 admitted to any Danish ICU from 10 March to 19 May 2020 and registered demographics, chronic comorbidities, use of organ support, length of stay, and vital status from patient files. Risk factors for death were analyzed using adjusted Cox regression analysis.

RESULTS

There were 323 ICU patients with confirmed COVID-19. Median age was 68 years, 74% were men, 50% had hypertension, 21% diabetes, and 20% chronic pulmonary disease; 29% had no chronic comorbidity. Invasive mechanical ventilation was used in 82%, vasopressors in 83%, renal replacement therapy in 26%, and extra corporeal membrane oxygenation in 8%. ICU stay was median 13 days (IQR 6-22) and hospital stay 19 days (11-30). Median follow-up was 79 days. At end of follow-up, 118 had died (37%), 15 (4%) were still in hospital hereof 4 in ICU as of 16 June 2020. Risk factors for mortality included male gender, age, chronic pulmonary disease, active cancer, and number of co-morbidities.

CONCLUSIONS

In this nationwide, population-based cohort of ICU patients with COVID-19, longer term survival was high despite high age and substantial use of organ support. Male gender, age, and chronic co-morbidities, in particular chronic pulmonary disease, were associated with increased risk of death.

Transatlantic transferability of a new reinforcement learning model for optimizing haemodynamic treatment for critically ill patients with sepsis

INTRODUCTION

In recent years, reinforcement learning (RL) has gained traction in the healthcare domain. In particular, RL methods have been explored for haemodynamic optimization of septic patients in the Intensive Care Unit. Most hospitals however, lack the data and expertise for model development, necessitating transfer of models developed using external datasets. This approach assumes model generalizability across different patient populations, the validity of which has not previously been tested. In addition, there is limited knowledge on safety and reliability. These challenges need to be addressed to further facilitate implementation of RL models in clinical practice.

METHOD

We developed and validated a new reinforcement learning model for hemodynamic optimization in sepsis on the MIMIC intensive care database from the USA using a dueling double deep Q network. We then transferred this model to the European AmsterdamUMCdb intensive care database. T-Distributed Stochastic Neighbor Embedding and Sequential Organ Failure Assessment scores were used to explore the differences between the patient populations. We apply off-policy policy evaluation methods to quantify model performance. In addition, we introduce and apply a novel deep policy inspection to analyse how the optimal policy relates to the different phases of sepsis and sepsis treatment to provide interpretable insight in order to assess model safety and reliability.

RESULTS

The off-policy evaluation revealed that the optimal policy outperformed the physician policy on both datasets despite marked differences between the two patient populations and physician's policies. Our novel deep policy inspection method showed insightful results and unveiled that the model could initiate therapy adequately and adjust therapy intensity to illness severity and disease progression which indicated safe and reliable model behaviour. Compared to current physician behavior, the developed policy prefers a more liberal use of vasopressors with a more restrained use of fluid therapy in line with previous work.

CONCLUSION

We created a reinforcement learning model for optimal bedside hemodynamic management and demonstrated model transferability between populations from the USA and Europe for the first time. We proposed new methods for deep policy inspection integrating expert domain knowledge. This is expected to facilitate progression to bedside clinical decision support for the treatment of critically ill patients.

Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment

BACKGROUND

There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists.

METHODS

We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients' characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD).

RESULTS

A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain.

CONCLUSIONS

ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist's decision took priority. Further research is needed to improve the matching of the physicians' decision with the patient's wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530 .

Actualización de la Declaración de consenso en medicina critica para la atención multidisciplinaria del paciente con sospecha o confirmación diagnóstica de COVID-19

Antecedentes y objetivos

La enfermedad por coronavirus de 2019 (COVID-19) es una enfermedad ocasionada por el nuevo coronavirus del síndrome respiratorio agudo grave (SARS-CoV-2). Se identificó por primera vez en diciembre de 2019 en la ciudad de Wuhan, en los meses siguientes se expandió rápidamente a todos los continentes y la Organización Mundial de la Salud (OMS) la reconoció como una pandemia global el 11 de marzo de 2020. La mayoría de los individuos son asintomáticos pero una baja proporción ingresan a cuidados intensivos con una alta morbimortalidad. Este consenso tiene como objetivo actualizar la declaratoria inicial emitida por la Asociación Colombiana de Medicina Crítica (AMCI) para el manejo del paciente críticamente enfermo con COVID-19, dentro de las áreas críticas de las instituciones de salud.

Métodos

Este estudio utilizó dos técnicas de consenso formal para construir las recomendaciones finales: Delphi modificada y grupos nominales. Se construyeron preguntas por la estrategia PICO. 10 grupos nominales desarrollaron recomendaciones para cada unidad temática. El producto del consenso fue evaluado y calificado en una ronda Delphi y se discutió de forma virtual por los relatores de cada núcleo y los representantes de sociedades médicas científicas afines al manejo del paciente con COVID-19.

Resultados

80 expertos nacionales participaron en la actualización del consenso AMCI, especialistas en Medicina Critica y Cuidados Intensivos, Nefrología, Neurología, Neumología, bioeticistas, Medicina interna, Anestesia, Cirugía General, Cirugía de cabeza y cuello, Cuidados Paliativos, Enfermeras Especialistas en Medicina crítica, Terapeutas respiratorias especialistas en medicina crítica y Fisioterapia, con experiencia clínica en la atención del paciente críticamente enfermo. La declaratoria emite recomendaciones en los ámbitos más relevantes para la atención en salud de los casos de COVID-19, al interior de las unidades de cuidados intensivos, en el contexto nacional de Colombia.

Conclusiones

Un grupo significativo multidisciplinario de profesionales expertos en medicina crítica emiten, mediante técnicas de consenso formal, recomendaciones sobre la mejor práctica para la atención del paciente críticamente enfermo con COVID-19. Las recomendaciones deben ser adaptadas a las condiciones específicas, administrativas y estructurales de las distintas unidades de cuidados intensivos del país.

Brunkhorst* F. Long-Term Survival Following Sepsis

BACKGROUND

There have not yet been any prospective registry studies in Germany with active investigation of the long-term survival of patients with sepsis.

METHODS

The Jena Sepsis Registry (JSR) included all patients with a diagnosis of sepsis in the four intensive care units of Jena University Hospital from January 2011 to December 2015. Long-term survival 6-48 months after diagnosis was documented by asking the treating general practitioners. The survival times were studied with Kaplan-Meier estimators. Cox regressions were calculated to show associations between possible predictors and survival time.

RESULTS

1975 patients with sepsis or septic shock were included. The mean time of observation was 730 days. For 96.4% of the queries to the general practitioners, information on long-term survival was available. Mortality in the intensive care unit was 34% (95% confidence interval [32; 37]), and in-hospital mortality was 45% [42; 47]. The overall mortality six months after diagnosis was 59% [57; 62], the overall mortality 48 months after diagnosis was 74% [72; 78]. Predictors of shorter survival were age, nosocomial origin of sepsis, diabetes, cerebrovascular disease, duration of stay in the intensive care unit, and renal replacement therapy.

CONCLUSION

The nearly 75% mortality four years after diagnosis indicates that changes are needed both in the acute treatment of patients with sepsis and in their multi-sector long-term care. The applicability of these findings may be limited by their having been obtained in a single center.

Discharge from hospital with newly administered antipsychotics after intensive care unit delirium - Incidence and contributing factors

PURPOSE

Delirium in the intensive care unit (ICU) is often treated with haloperidol or atypical antipsychotics. Antipsychotic treatment can lead to severe adverse effects and excess mortality. After initiation in the ICU, patients are at risk of having their antipsychotics continued unnecessarily at ICU and hospital discharge. This study aims to determine the incidence of, and risk factors for antipsychotic continuation at hospital discharge after ICU delirium.

METHODS

This retrospective observational study was performed in a tertiary care center. Adult patients who received antipsychotics for ICU delirium during 2016 were included. Data was extracted from patient records. After univariate testing, a multivariate binary logistic regression model was used to identify independent risk factors for antipsychotic continuation.

RESULTS

A total of 196 patients were included, of which 104 (53.1%) and 41 (20.9%) had their antipsychotics continued at ICU and hospital discharge respectively. Medical ICU admission (odds ratio [95% confidence interval] 2.97 [1.37-6.41]) and quetiapine treatment (5.81 [1.63-20.83]) were independently associated with antipsychotic continuation at hospital discharge.

CONCLUSIONS

Approximately one in five patients were discharged from the hospital with continued antipsychotics. Hospital policies should implement strategies for systematic antipsychotic tapering and better follow-up of antipsychotics at transitions of care.

Telemedicine in the ICU: Innovation in the Critical Care Process

Tele-ICU is a technology-based model designed to deliver effective critical care in the intensive care unit (ICU). The tele-ICU system has been developed to address the increasing demand for intensive care services and the shortage of intensivists. A finite number of intensivists from remote locations provide real-time services to multiple ICUs and assist in the treatment of critically ill patients. Risk prediction algorithms, smart alarm systems, and machine learning tools augment conventional coverage and can potentially improve the quality of care. Tele-ICU is associated with substantial improvements in mortality, reduced hospital and ICU length of stay, and decreased health care costs. Although multiple studies show improved outcomes following the implementation of tele-ICU, results are not consistent. Several factors, including the heterogeneity of tele-ICU infrastructure deployed in different facilities and the reluctance of health care workers to accept tele-ICU, could be associated with these varied results. Considerably high installation and ongoing operational costs might also be limiting the widespread utilization of this innovative service. While we believe that the implementation of tele-ICU offers potential advantages and makes critical care delivery more efficient, further research on the impact of this technology in critical care settings is warranted.

Intensive Care Unit Organization and Interdisciplinary Care for Critically Ill Patients with Cancer

Patients with cancer are at high risk of developing acute critical illness requiring intensive care unit (ICU) admission. Critically ill patients with cancer have complex medical needs that can best be served by a multidisciplinary ICU care team. This article provides an overview of the current state-of-the-art in multidisciplinary care for critically ill patients with cancer. Better integration of multidisciplinary critical care into the continuum of care for patients with cancer offers the prospect of further improvements in the outcomes of patients with cancer.

Epidemiology and outcomes of invasive mechanical ventilation without ICU admission in acute care hospitals in Texas: A population-based cohort study

PURPOSE

The high ICU bed capacity in the United States (US) allows ICU care of patients requiring invasive mechanical ventilation (IMV), absent public health crisis. The use of IMV without ICU admission (non-ICU) in acute care hospitals in the US and its impact on patients' outcomes were not examined.

METHODS

A retrospective cohort study was performed using statewide inpatient data in Texas to identify hospitalizations aged ≥18 years receiving IMV in acute care hospitals with ICU care capability during January 2014 through September 2015. Use of non-ICU IMV, patient characteristics, and hospital mortality were examined.

RESULTS

Among 136,728 IMV hospitalizations, 4531 (3.3%) were non-ICU. As compared to ICU admissions, non-ICU IMV hospitalizations were younger (age 18-44 years: 24.9% vs. 17.2%), with lower burden of major comorbidities (no major comorbidity: 24.7% vs. 14.5%), and lower occurrence of non-respiratory organ failures (no non-respiratory organ failure: 32.7% vs. 19.8%). Risk-adjusted hospital mortality of non-ICU vs. ICU IMV hospitalizations was 48.7% (95% CI 48.1-49.4) and 29.9% (95% CI 29.8-30.0), respectively.

CONCLUSIONS

Non-ICU IMV was provided in 1 in 30 IMV hospitalizations in acute care hospitals. Although non-ICU IMV hospitalizations were younger and healthier than those admitted to ICU, their hospital mortality was markedly higher.

Enhanced Recovery after Intensive Care (ERIC): study protocol for a German stepped wedge cluster randomised controlled trial to evaluate the effectiveness of a critical care telehealth program on process quality and functional outcomes

INTRODUCTION

Survival after critical illness has noticeably improved over the last decades due to advances in critical care medicine. Besides, there is an increasing number of elderly patients with chronic diseases being treated in the intensive care unit (ICU). More than half of the survivors of critical illness suffer from medium-term or long-term cognitive, psychological and/or physical impairments after ICU discharge, which is recognised as post-intensive care syndrome (PICS). There are evidence-based and consensus-based quality indicators (QIs) in intensive care medicine, which have a positive influence on patients' long-term outcomes if adhered to.

METHODS AND ANALYSIS

The protocol of a multicentre, pragmatic, stepped wedge cluster randomised controlled, quality improvement trial is presented. During 3 predefined steps, 12 academic hospitals in Berlin and Brandenburg, Germany, are randomly selected to move in a one-way crossover from the control to the intervention condition. After a multifactorial training programme on QIs and clinical outcomes for site personnel, ICUs will receive an adapted, interprofessional protocol for a complex telehealth intervention comprising of daily telemedical rounds at ICU. The targeted sample size is 1431 patients. The primary objective of this trial is to evaluate the effectiveness of the intervention on the adherence to eight QIs daily measured during the patient's ICU stay, compared with standard of care. Furthermore, the impact on long-term recovery such as PICS-related, patient-centred outcomes including health-related quality of life, mental health, clinical assessments of cognition and physical function, all-cause mortality and cost-effectiveness 3 and 6 months after ICU discharge will be evaluated.

ETHICS AND DISSEMINATION

This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/006/18). The results will be published in a peer-reviewed scientific journal and presented at international conferences. Study findings will also be disseminated via the website (www.eric-projekt.net).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03671447).

Long-term cognitive impairment after ICU treatment: a prospective longitudinal cohort study (Cog-I-CU)

In this prospective cohort study we aimed to investigate the trajectory of the cognitive performance of patients after discharge from an intensive care unit (ICU). Special consideration was given to patients with suspected premorbid cognitive impairment who might be at risk for the development of dementia. Clinical characteristics were collected until discharge. The premorbid cognitive state was estimated by a structured interview with a close relative. Cognitive outcome was assessed using the Consortium to Establish a Registry of Alzheimer’s Disease (CERAD) Plus battery and the Stroop Color and Word Test at the time of discharge from ICU and 9 months later. The results of the study group were compared to an established healthy control group and to normative data. A total number of 108 patients were finally included. At the time of discharge, patients underperformed the healthy control group. In linear regression models, delirium during the ICU stay and the factor premorbid cognitive impairment were associated with poorer cognitive outcome (p = 0.047 and p = 0.001). After 9 months, in 6% of patients without evidence of premorbid cognitive impairment long-lasting deficits were found. In patients with suspected premorbid cognitive impairment, performance in tests of executive function failed to improve.

Linking of global intensive care (LOGIC): An international benchmarking in critical care initiative

Benchmarking is a common and effective method for measuring and analyzing ICU performance. With the existence of national registries, objective information can now be obtained to allow benchmarking of ICU care within and between countries. The present manuscript briefly describes the current status of benchmarking in healthcare and critical care and presents the LOGIC project, an initiative to promote international benchmarking for intensive care units. Currently 13 registries have joined LOGIC. We showed large differences in the utilization of ICU as well as resources and in outcomes. Despite the need for careful interpretation of differences due to variation in definitions and limited risk adjustment, LOGIC is a growing worldwide initiative that allows access to insightful epidemiologic data from ICUs in multiple databases and registries.

Intensive Care Unit Bed Utilization and Head Injury Burden in a Resource-Poor Setting

INTRODUCTION

In high-income countries (HICs), the intensive care unit (ICU) bed density is approximately 20-32 beds/100 000 population compared with countries in sub-Saharan Africa, like Malawi, with an ICU bed density of 0.1 beds/100 000 population. We hypothesize that the ICU bed utilization in Malawi will be high.

METHODS

This is an observational study at a tertiary care center in Malawi from August 2016 to May 2018. Variables used to evaluate ICU bed utilization include ICU length of stay (LOS), bed occupancy rates (average daily ICU census/number of ICU beds), bed turnover (total number of admissions/number of ICU beds), and turnover intervals (number of ICU bed days/total number of admissions - average ICU LOS).

RESULTS

494 patients were admitted to the ICU during the study period. The average LOS during the study period was 4.8 ± 6.0 days. Traumatic brain injury patients had the most extended LOS (8.7 ± 6.8 days) with a 49.5% ICU mortality. The bed occupancy rate per year was 74.7%. The calculated bed turnover was 56.5 persons treated per bed per year. The average turnover interval, defined as the number of days for a vacant bed to be occupied by the successive patient admission, was 1.63 days.

CONCLUSION

Despite the high burden of critical illness, the bed occupancy rates, turn over days, and turnover interval reveal significant underutilization of the available ICU beds. ICU bed underutilization may be attributable to the absence of an admission and discharge protocols. A lack of brain death policy further impedes appropriate ICU utilization.

The Urge to Build More Intensive Care Unit Beds and Ventilators: Intuitive but Errant

Throughout the COVID-19 crisis, much attention has been devoted to the fraught question of how to allocate intensive care unit beds and mechanical ventilators if the supply of these resources is insufficient to provide them to all patients considered to be in need. The authors believe that the deployment of aggressive medical technology to win the “war” against the pandemic may represent the triumph of deeply human instincts over optimal policy.

Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge

IMPORTANCE

Delays in transfer for discharge-ready patients from the intensive care unit (ICU) are increasingly described and contribute to strained capacity.

OBJECTIVE

To describe the epidemiological features and health care costs attributable to potentially avoidable delays in ICU discharge in a large integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was performed in 17 adult ICUs in Alberta, Canada, from June 19, 2012, to December 31, 2016. Participants were patients 15 years or older admitted to a study ICU during the study period. Data were analyzed from October 19, 2018, to May 20, 2020.

EXPOSURES

Avoidable time in the ICU, defined as the portion of total ICU patient-days accounted for by avoidable delay in ICU discharge (eg, waiting for a ward bed).

MAIN OUTCOMES AND MEASURES

The primary outcome was health care costs attributable to avoidable time in the ICU. Secondary outcomes were factors associated with avoidable time, in-hospital mortality, and measures of use of health care resources, including the number of hours in the ICU and the number of days of hospitalization. Multilevel mixed multivariable regression was used to assess associations between avoidable time and outcomes.

RESULTS

In total, 28 904 patients (mean [SD] age, 58.3 [16.8] years; 18 030 male [62.4%]) were included. Of these, 19 964 patients (69.1%) had avoidable time during their ICU admission. The median avoidable time per patient was 7.2 (interquartile range, 2.4-27.7) hours. In multivariable analysis, male sex (odds ratio [OR], 0.92; 95% CI, 0.87-0.98), comorbid hemiplegia or paraplegia (OR 1.47; 95% CI, 1.23-1.75), liver disease (OR 1.20; 95% CI, 1.04-1.37), admission Acute Physiology and Chronic Health Evaluation II score (OR, 1.03; 95% CI, 1.02-1.03), surgical status (OR, 0.90; 95% CI, 0.82-0.98), medium community hospital type (OR, 0.12; 95% CI, 0.04-0.32), and admission year (OR, 1.16; 95% CI, 1.13-1.19) were associated with avoidable time. The cumulative avoidable time was 19 373.9 days, with estimated attributable costs of CAD$34 323 522. Avoidable time accounted for 12.8% of total ICU bed-days and 6.4% of total ICU costs. Patients with avoidable time before ICU discharge showed higher unadjusted in-hospital mortality (1115 [5.6%] vs 392 [4.4%]; P < .001); however, in multivariable analysis, avoidable time was associated with reduced in-hospital mortality (adjusted hazard ratio, 0.74; 95% CI, 0.64-0.85). Results were similar in sensitivity analyses.

CONCLUSIONS AND RELEVANCE

In this study, potentially avoidable discharge delay occurred for most patients admitted to ICUs across a large integrated health system and translated into substantial associated health care costs.

Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis

PURPOSE

To investigate the global burden of sepsis in hospitalized adults by updating and expanding a systematic review and meta-analysis and to compare findings with recent Institute for Health Metrics and Evaluation (IHME) sepsis estimates.

METHODS

Thirteen electronic databases were searched for studies on population-level sepsis incidence defined according to clinical criteria (Sepsis-1, -2: severe sepsis criteria, or sepsis-3: sepsis criteria) or relevant ICD-codes. The search of the original systematic review was updated for studies published 05/2015-02/2019 and complemented by a search targeting low- or middle-income-country (LMIC) studies published 01/1979-02/2019. We performed a random-effects meta-analysis with incidence of hospital- and ICU-treated sepsis and proportion of deaths among these sepsis cases as outcomes.

RESULTS

Of 4746 results, 28 met the inclusion criteria. 21 studies contributed data for the meta-analysis and were pooled with 30 studies from the original meta-analysis. Pooled incidence was 189 [95% CI 133, 267] hospital-treated sepsis cases per 100,000 person-years. An estimated 26.7% [22.9, 30.7] of sepsis patients died. Estimated incidence of ICU-treated sepsis was 58 [42, 81] per 100,000 person-years, of which 41.9% [95% CI 36.2, 47.7] died prior to hospital discharge. There was a considerably higher incidence of hospital-treated sepsis observed after 2008 (+ 46% compared to the overall time frame).

CONCLUSIONS

Compared to results from the IHME study, we found an approximately 50% lower incidence of hospital-treated sepsis. The majority of studies included were based on administrative data, thus limiting our ability to assess temporal trends and regional differences. The incidence of sepsis remains unknown for the vast majority of LMICs, highlighting the urgent need for improved epidemiological sepsis surveillance.

Delivery of hepato-pancreato-biliary surgery during the COVID-19 pandemic: an European-African Hepato-Pancreato-Biliary Association (E-AHPBA) cross-sectional survey

BACKGROUND

The extent of the COVID-19 pandemic and the resulting response has varied globally. The European and African Hepato-Pancreato-Biliary Association (E-AHPBA), the premier representative body for practicing HPB surgeons in Europe and Africa, conducted this survey to assess the impact of COVID-19 on HPB surgery.

METHODS

An online survey was disseminated to all E-AHPBA members to assess the effects of the pandemic on unit capacity, management of HPB cancers, use of COVID-19 screening and other aspects of service delivery.

RESULTS

Overall, 145 (25%) members responded. Most units, particularly in COVID-high countries (>100,000 cases) reported insufficient critical care capacity and reduced HPB operating sessions compared to COVID-low countries. Delayed access to cancer surgery necessitated alternatives including increased neoadjuvant chemotherapy for pancreatic cancer and colorectal liver metastases, and locoregional treatments for hepatocellular carcinoma. Other aspects of service delivery including COVID-19 screening and personal protective equipment varied between units and countries.

CONCLUSION

This study demonstrates that the COVID-19 pandemic has had a profound adverse impact on the delivery of HPB cancer care across the continents of Europe and Africa. The findings illustrate the need for safe resumption of cancer surgery in a "new" normal world with screening of patients and staff for COVID-19.

Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival

OBJECTIVES

Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions.

DATA SOURCES

PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies.

STUDY SELECTION

Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email.

DATA EXTRACTION

References and data were based on relevance and author consensus.

DATA SYNTHESIS

We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients.

CONCLUSIONS

Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

Sleep Fragmentation and Cognitive Trajectories After Critical Illness

BACKGROUND

ICU survivors can experience both cognitive dysfunction and persistent sleep disturbances after hospitalization. Sleep disturbances have been linked with cognitive impairment in various patient populations, and the apolipoprotein E (APOE) genotype has been linked to sleep-related impairments in cognition.

RESEARCH QUESTION

Is there an association between sleep, long-term cognition, and APOE status in ICU survivors?

STUDY DESIGN AND METHODS

We enrolled 150 patients from five centers who had been mechanically ventilated for at least 3 days; 102 patients survived to ICU discharge. Actigraphy and cognitive testing were undertaken at 7 days, 6 months, and 12 months after ICU discharge, and sleep duration, quality, and timing were estimated by actigraphy. APOE single nucleotide polymorphisms were assessed for each patient.

RESULTS

Actigraphy-estimated sleep fragmentation, but not total sleep time or interdaily stability (estimate of circadian rhythmicity), was associated with worse cognitive impairment at 7 days of ICU discharge. No actigraphy-estimated variable of sleep estimation at 7 days post-ICU discharge predicted cognitive impairment or persistent sleep abnormalities at 6 and 12 months of follow-up in subsequently assessed survivors. Possessing the APOE ε4 allele was not significantly associated with sleep disturbances and its presence did not modify the risk of sleep-related cognitive impairment at follow-up.

INTERPRETATION

Sleep fragmentation estimated by actigraphy was associated with worse cognitive performance in hospital, but not at later time intervals. Further research is needed to better delineate the relationship between persistent sleep disturbances and cognition in larger numbers of ICU survivors.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02086877; URL: www.clinicaltrials.gov.

Acute Lung Injury in Critically Ill Patients: Actin-Scavenger Gelsolin Signals Prolonged Respiratory Failure

Background:

Gelsolin is an actin-scavenger controlling the tissue damage from actin in the blood. Gelsolin levels in circulation drops when tissue damage and corresponding actin release is pronounced due to catabolic conditions. The purpose of this study was to determine if low plasma gelsolin independently predicts a reduced chance of weaning from ventilator-demanding respiratory failure in critically ill patients within 28 days from admission.

Results:

This cohort study included 746 critically ill patients with ventilator-demanding respiratory failure from the randomized clinical trial, “Procalcitonin And Survival Study (PASS).” Primary end point was successful weaning from mechanical ventilation within 28 days. We used multivariable Cox regression adjusted for age, sepsis, PaO₂/FiO₂ ratio and other known and suspected predictors of persistent respiratory failure. Follow-up was complete.

For medical patients, baseline-gelsolin below the 25th percentile independently predicted a 40% lower chance of successful weaning within 28 days (HR 0.60, 95% CI 0.46–0.79, P = 0.0002); among surgical patients this end point was not predicted. Low gelsolin levels predicted chance of being “alive and out of intensive care at day 14” for both medical and surgical patients (HR 0.69, 95% CI 0.54–0.89, P = 0.004). Gelsolin levels did not predict 28 day mortality for surgical or medical patients.

Conclusions:

Low levels of serum gelsolin independently predict a decreased chance of successful weaning from ventilator within 28 days among medical intensive care patients. This finding has implications for identifying patients who need individualized intervention early in intensive care course to prevent unfavorable lung prognosis in acute respiratory failure.

Trial registration:

This is a substudy to the PASS, Clinicaltrials.gov ID: NCT00271752, first registered January 1, 2006.

Would the United States Have Had Too Few Beds for Universal Emergency Care in the Event of a More Widespread Covid-19 Epidemic?

(1) Background: To evaluate the level of hospital bed numbers in U.S. states relative to other countries using a new method for evaluating bed numbers, and to determine if this is sufficient for universal health care during a major Covid-19 epidemic in all states (2) Methods: Hospital bed numbers in each state were compared using a new international comparison methodology. Covid-19 deaths per 100 hospital beds were used as a proxy for bed capacity pressures. (3) Results: Hospital bed numbers show large variation between U.S. states and half of the states have equivalent beds to those in developing countries. Relatively low population density in over half of US states appeared to have limited the spread of Covid-19 thus averting a potential major hospital capacity crisis. (4) Conclusions: Many U.S. states had too few beds to cope with a major Covid-19 epidemic, but this was averted by low population density in many states, which seemed to limit the spread of the virus.

Role Incongruence and Psychological Stress Symptoms in Substitute Decision Makers of Intensive Care Patients

BACKGROUND

Most intensive care patients require substitute decision makers (SDMs) to make decisions. The SDMs may prefer an active, shared, or passive decision-making role. Role incongruence is when preferred and actual roles differ.

OBJECTIVE

To evaluate the impact of decision-making role preferences and role incongruence on psychological distress symptoms in SDMs.

METHODS

A multicenter, interviewer-administered survey was conducted among SDMs of critically ill adults. The Control Preferences Scale was used to evaluate role preferences. Psychological distress was defined as anxiety, depression, or posttraumatic stress symptoms with predefined cut points on the Hospital Anxiety and Depression Scale (score > 10 on the anxiety or the depression subscale) and Impact of Events Scale (score > 30).

RESULTS

One hundred eighty SDMs were recruited; 64% responded. Most were white (71%) and female (65%); 46% were spouses. Role preferences varied: active, 24%; shared, 44%; and passive, 31%. Almost half (49%) reported incongruence. Symptom prevalence was 50% for posttraumatic stress, 32% for anxiety, and 16% for depression. Most (56%) reported some psychological distress. In multivariable logistic regression, the composite outcome of psychological distress was independently associated with patient death (odds ratio, 2.95; 95% CI, 1.08-8.02; P = .03), female sex of SDM (odds ratio, 2.96; 95% CI, 1.49-5.89; P = .002), and incongruence (odds ratio, 3.26; 95% CI, 1.67-6.36; P < .001).

CONCLUSIONS

Adverse psychological symptoms are prevalent in SDMs of critically ill patients and are related to role incongruence.

COVID-19 and US Health Financing: Perils and Possibilities

While the COVID-19 pandemic presents every nation with challenges, the United States’ underfunded public health infrastructure, fragmented medical care system, and inadequate social protections impose particular impediments to mitigating and managing the outbreak. Years of inadequate funding of the nation’s federal, state, and local public health agencies, together with mismanagement by the Trump administration, hampered the early response to the epidemic. Meanwhile, barriers to care faced by uninsured and underinsured individuals in the United States could deter COVID-19 care and hamper containment efforts, and lead to adverse medical and financial outcomes for infected individuals and their families, particularly those from disadvantaged groups. While the United States has a relatively generous supply of Intensive Care Unit beds and most other health care infrastructure, such medical resources are often unevenly distributed or deployed, leaving some areas ill-prepared for a severe respiratory epidemic. These deficiencies and shortfalls have stimulated a debate about policy solutions. Recent legislation, for instance, expanded coverage for testing for COVID-19 for the uninsured and underinsured, and additional reforms have been proposed. However comprehensive health care reform – for example, via national health insurance – is needed to provide full protection to American families during the COVID-19 outbreak and in its aftermath.

The SAPS 3 score as a predictor of hospital mortality in a South African tertiary intensive care unit: A prospective cohort study

BACKGROUND

No African countries were included in the development of the Simplified Acute Physiology Score 3 (SAPS 3). This study aimed to assess the performance of the SAPS 3 as a predictor of hospital mortality in patients admitted to a multi-disciplinary tertiary intensive care unit (ICU) in South Africa.

METHODS

A prospective cohort study was undertaken in a tertiary single-centre closed multidisciplinary ICU with 16 beds over 12 months in 2017. First time admissions 12 years and over were included. Exclusions were patients who died within six hours of admission, incomplete data sets and unknown outcome after ICU discharge. Demographic data, clinical admission data and co-morbidities were recorded. The SAPS 3 score was calculated within the first hour of ICU admission. The highest Sequential Organ Failure Assessment score, vasopressor use, mechanical ventilation requirements and details of acute kidney injury, if present, were recorded. Discrimination of the model was evaluated using an area under the receiver operating characteristic curve (AUROC) and calibration by the Hosmer-Lemeshow (HL) Goodness of Fit Test (Ĉ and Ĥ statistic). The observed versus the SAPS 3 model predicted mortality ratios were compared and the standardized mortality ratio (SMR) was calculated.

RESULTS

A total of 829 admissions with a mean SAPS 3 (SD) of 48.1 (16) were included. Of patients with a known human immunodeficiency virus (HIV) status, 32,4% were positive. The ICU and hospital mortality rates were 13.3% and 21.4% respectively. The SAPS 3 model had a AUROC of 0.796 and HL Ĉ and Ĥ statistics were 12.1 and 11.8 (p-values 0.15 and 0.16). The SMR for the model was 1.002 (95%CI: 0.91-1.10). The mortality of 41% for the subgroup with sepsis/septic shock was higher than predicted with a SMR of 1.24 (95% CI 1.11-1.37).

CONCLUSIONS

The SAPS 3 model showed good calibration and fair discrimination when applied to the cohort. The SAPS 3 model can be used to describe the case mix in this African ICU with a high incidence of HIV. Ongoing efforts should be made to improve outcomes of septic patients.

Intensive care inequity in Rio de Janeiro: the effect of spatial distribution of health services on severe acute respiratory infection

OBJECTIVE

To analyze the distribution of adult intensive care units according to geographic region and health sector in Rio de Janeiro and to investigate severe acute respiratory infection mortality in the public sector and its association with critical care capacity in the public sector.

METHODS

We evaluated the variation in intensive care availability and severe acute respiratory infection mortality in the public sector across different areas of the city in 2014. We utilized databases from the National Registry of Health Establishments, the Brazilian Institute of Geography and Statistics, the National Mortality Information System and the Hospital Admission Information System.

RESULTS

There is a wide range of intensive care unit beds per capita (from 4.0 intensive care unit beds per 100,000 people in public hospitals in the West Zone to 133.6 intensive care unit beds per 100,000 people in private hospitals in the Center Zone) in the city of Rio de Janeiro. The private sector accounts for almost 75% of the intensive care unit bed supply. The more developed areas of the city concentrate most of the intensive care unit services. Map-based spatial analysis shows a lack of intensive care unit beds in vast territorial extensions in the less developed regions of the city. There is an inverse correlation (r = -0.829; 95%CI -0.946 to -0.675) between public intensive care unit beds per capita in different health planning areas of the city and severe acute respiratory infection mortality in public hospitals.

CONCLUSION

Our results show a disproportionate intensive care unit bed provision across the city of Rio de Janeiro and the need for a rational distribution of intensive care.

Influence of bedspacing on outcomes of hospitalised medicine service patients: a retrospective cohort study

BACKGROUND

Specialty wards cohort hospitalised patients to improve outcomes and lower costs. When demand exceeds capacity, patients overflow and are "bedspaced" to alternate wards. Some studies have demonstrated that bedspacing among medicine service patients is associated with adverse patient-centred outcomes, however, results have been inconsistent and have primarily been performed within national health systems. The objective of this study was to assess the association of bedspacing with patient-centred outcomes among United States patients admitted to general medicine services.

METHODS

We performed a retrospective cohort study of internal medicine, family medicine and geriatric service patients who were bedspaced vs cohorted for the entirety of their hospital stay within three large, urban United States hospitals (quaternary referral centre, tertiary referral centre and community hospital, with different patient demographics and case-mixes) in 2014 and 2015. We performed quantile regression to determine differences in length of stay (LOS) between bedspaced vs cohorted patients and logistic regression for in-hospital mortality and discharge to home.

RESULTS

Among 18 802 patients in 33 wards, 6119 (33%) patients were bedspaced. Bedspaced patients had significantly longer LOS compared with cohorted patients at the 25^th (0.1 days, 95% CI: 0.05 to 0.2, p=0.001), 50^th (0.2 days, 95% CI: 0.1 to 0.3, p=0.003) and 75^th (0.3 days, 95% CI: 0.2 to 0.5, p<0.001) percentiles; and no statistically significant differences in odds of mortality (OR=0.9, 95% CI: 0.6 to 1.3, p=0.5) or discharge to home (OR=0.9, 95% CI: 0.9 to 1.0, p=0.06) in adjusted analyses.

CONCLUSION

Bedspacing is associated with adverse patient-centred outcomes. Future work is needed to confirm these findings, understand mechanisms contributing to adverse outcomes and identify factors that mitigate these adverse effects in order to provide high-value, patient-centred care to hospitalised patients.

Outcomes of diabetic ketoacidosis in a tertiary centre with restricted intensive care unit bed capacity

BACKGROUND

Diabetic ketoacidosis (DKA) is an acute metabolic condition, sometimes requiring admission to an intensive care unit (ICU).

AIMS

To investigate the outcomes of DKA patients admitted to a hospital with restricted ICU capacity.

METHODS

We included all DKA patients above age 18 who were admitted to a tertiary hospital during 2004-2017. We conducted multivariate logistic regression analysis adjusted for ICU bed availability to analyse parameters associated with ICU admission, and a composite outcome of mortality, DKA recurrence and mechanical ventilation.

RESULTS

Among 382 DKA patients in our cohort, 94 (24.6%) were admitted to the ICU. The in-hospital mortality was 4.7%. Low bicarbonate (<10 mmoL/L) and pH (<7) levels at presentation were associated with ICU admission (P < 0.001 for both). In multivariate models availability of beds in the ICU was not associated with ICU admission, mortality or DKA recurrence of any type.

CONCLUSION

In a setting of limited ICU capacity, DKA treatment does not necessarily require admission to the ICU. When the rising rates of diabetes mellitus and the associated elevated rates of DKA are taken into account, our results highlight the importance of including step-down units when devising local protocols for care of these patients.

Demographic Shifts, Case Mix, Activity, and Outcome for Elderly Patients Admitted to Adult General ICUs in England, Wales, and Northern Ireland

OBJECTIVES

Major increases in the proportion of elderly people in the population are predicted worldwide. These population increases, along with improving therapeutic options and more aggressive treatment of elderly patients, will have major impact on the future need for healthcare resources, including critical care. Our objectives were to explore the trends in admissions, resource use, and risk-adjusted hospital mortality for older patients, admitted over a 20-year period between 1997 and 2016 to adult general ICUs in England, Wales, and Northern Ireland.

DESIGN

RETROSPECTIVE ANALYSIS OF NATIONAL CLINICAL AUDIT DATABASE.

SETTING

The Intensive Care National Audit & Research Centre Case Mix Programme Database, the national clinical audit for adult general ICUs in England, Wales, and Northern Ireland.

PATIENTS

All adult patients 16 years old or older admitted to adult general ICUs contributing data to the Case Mix Programme Database between January 1, 1997, and December 31, 2016.

MEASUREMENTS AND MAIN RESULTS

The annual number, trends, and outcomes for patients across four age bands (16-64, 65-74, 75-84, and 85+ yr) admitted to ICUs contributing to the Case Mix Programme Database from 1997 to 2016 were examined. Case mix, activity, and outcome were described in detail for the most recent cohort of patients admitted in 2015-2016. Between 1997 to 2016, the annual number of admissions to ICU of patients in the older age bands increased disproportionately, with increases that could not be explained solely by general U.K. demographic shifts. The risk-adjusted acute hospital mortality decreased significantly within each age band over the 20-year period of the study. Although acute severity at ICU admission was comparable with that of the younger age group, apart from cardiovascular and renal dysfunction, older patients received less organ support. Older patients stayed longer in hospital post-ICU discharge, and hospital mortality increased with age, but the majority of patients surviving to hospital discharge returned home.

CONCLUSIONS

Over the past two decades, elderly patients have been more commonly admitted to ICU than can be explained solely by the demographic shift. Importantly, as with the wider population, outcomes in elderly patients admitted to ICU are improving over time, with most patients returning home.

Rates of Mechanical Ventilation for Patients With Dementia in Ontario: A Population-Based Cohort Study

The number of elderly patients with dementia receiving invasive mechanical ventilation is increasing over time in the United States, while the balance of potential benefits and harms of intensive care interventions in this population is unclear. In this report, we describe trends in use of invasive mechanical ventilation in elderly individuals with and without dementia in Ontario, Canada, and provide projections of the use of invasive mechanical ventilation through 2025. We show that rates of invasive mechanical ventilation for elderly patients with dementia are increasing faster than for the rest of the elderly (nondementia) population.

Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair

BACKGROUND

The Pediatric Perioperative Surgical Home (PPSH) model is an integrative care model designed to provide better patient care and value by shifting focus from the patient encounter level to the overarching surgical episode of care. So far, no PPSH model has targeted a complex airway disorder. It was hypothesized that the development of a PPSH for laryngeal cleft repair would reduce the high rates of postoperative resource utilization observed in this population.

METHODS

Institutional review board approval was obtained for the purpose of data collection and analysis. A multidisciplinary team of anesthesiologists, surgeons, nursing staff, information technology specialists, and finance administrators was gathered during the PPSH development phase. Standardized perioperative (preoperative, intraoperative, and postoperative) protocols were developed, with a focus on preoperative risk stratification. Patients presenting before surgery with ≥1 predefined medical comorbidity were triaged to the intensive care unit (ICU) postoperatively, while patients without severe systemic disease were triaged to a lower-acuity floor for overnight observation. The success of the PPSH protocol was defined by quality outcome and value measurements.

RESULTS

The PPSH initiative included 120 patients, and the pre-PPSH period included 115 patients who underwent laryngeal cleft repair before implementation of the new process. Patients in the pre-PPSH period were reviewed and classified as ICU candidates or lower acuity floor candidates had they presented in the post-PPSH period. Among the 79 patients in the pre-PPSH period who were identified as candidates for the lower-acuity floor transfer, 70 patients (89%) were transferred to the ICU (P < .001). Retrospective analysis concluded that 143 ICU bedded days could have been avoided in the pre-PPSH group by using PPSH risk stratification. Surgery duration (P = .034) and hospital length of stay (P = .015) were found to be slightly longer in the group of pre-PPSH observation unit candidates. Rates of 30-day unplanned readmissions to the hospital were not associated with the new PPSH initiative (P = .093). No patients in either group experienced emergent postoperative intubation or other expected complications. Total hospital costs were not lower for PPSH observation unit patients as compared to pre-PPSH observation unit candidates (difference = 8%; 95% confidence interval, -7% to 23%).

CONCLUSIONS

A well-defined preoperative screening protocol for patients undergoing laryngeal cleft repair can reduce postoperative ICU utilization without affecting patient safety. Further research is needed to see if these findings are applicable to other complex airway surgeries.

One-year mortality among non-surgical patients with hematological malignancies admitted to the intensive care unit: a Danish nationwide population-based cohort study

PURPOSE

Contemporary data on mortality of hematological patients admitted to the intensive care unit (ICU) are missing. In a Danish nationwide set-up, we assessed 30-day and 1-year mortality in this population including impact of age and comorbidity, with non-hematological patients as reference.

METHODS

This population-based cohort study included all non-surgical patients > 15 years of age admitted to an ICU in Denmark between 2010 and 2015. Data on hematological malignancies were obtained from the Danish Hematological Database, and information on the Charlson Comorbidity Index was obtained from the Danish National Patient Registry. Thirty-day and 1-year mortality was estimated using the Kaplan-Meier method. We used Cox proportional hazards regression to estimate hazard ratios.

RESULTS

We included 2122 ICU patients with a hematological malignancy and 88,951 non-hematological ICU patients. The 30-day mortality was 44% (95% confidence interval: 42-47%) among hematological patients and 27% (27-27%) among non-hematological patients. Similarly, 1-year mortality was 66% (64-68%) and 37% (37-37%), respectively. The corresponding hazard ratio with adjustment for age, sex, and comorbidity was 1.62 (1.54-1.71). Excess mortality was observed in all subgroups of age or of comorbidity. For example, the 1-year mortality for patients with Charlson Comorbidity Index Score > 3: 70% (66-74%) among hematological patients and 62% (61-63%) among non-hematological patients.

CONCLUSION

ICU patients with hematological malignancy had higher mortality than other ICU patients. However, one third of critically ill patients with a hematological malignancy is alive 1 year after ICU admission.

Persistent Inflammation, Immunosuppression and Catabolism Syndrome (PICS) after Polytrauma: A Rare Syndrome with Major Consequences

Nowadays, more trauma patients develop chronic critical illness (CCI), a state characterized by prolonged intensive care. Some of these CCI patients have disproportional difficulties to recover and suffer from recurrent infections, a syndrome described as the persistent inflammation, immunosuppression and catabolism syndrome (PICS). A total of 78 trauma patients with an ICU stay of ≥14 days (CCI patients) between 2007 and 2017 were retrospectively included. Within this group, PICS patients were identified through two ways: (1) their clinical course (≥3 infectious complications) and (2) by laboratory markers suggested in the literature (C-reactive protein (CRP) and lymphocytes), both in combination with evidence of increased catabolism. The incidence of PICS was 4.7 per 1000 multitrauma patients. The sensitivity and specificity of the laboratory markers was 44% and 73%, respectively. PICS patients had a longer hospital stay (median 83 vs. 40, p < 0.001) and required significantly more surgical interventions (median 13 vs. 3, p = 0.003) than other CCI patients. Thirteen PICS patients developed sepsis (72%) and 12 (67%) were readmitted at least once due to an infection. In conclusion, patients who develop PICS experience recurrent infectious complications that lead to prolonged hospitalization, many surgical procedures and frequent readmissions. Therefore, PICS forms a substantial burden on the patient and the hospital, despite its low incidence.

Epidemiology and outcomes of sepsis among hospitalizations with systemic lupus erythematosus admitted to the ICU: a population-based cohort study

Background

Sepsis is the most common cause of premature death among patients with systemic lupus erythematosus (SLE) aged ≤ 50 years in the United States, and infection is the most common cause of admission to the ICU among SLE patients. However, there are no population-level data on the patterns of the demand for critical care services among hospitalized septic patients with SLE or the outcomes of those admitted to the ICU.

Methods

We performed a retrospective cohort study, using the Texas Inpatient Public Use Data File, to identify SLE hospitalizations aged ≥ 18 years and the subgroups with sepsis and ICU admission during 2009–2014. The patterns of ICU admission among septic hospitalizations were examined. Logistic regression modeling was used to identify predictors of short-term mortality (defined as hospital death or discharge to hospice) among ICU admissions with sepsis and to estimate the risk-adjusted short-term mortality among ICU admissions with and without sepsis.

Results

Among 94,338 SLE hospitalizations, 17,037 (18.1%) had sepsis and 9409 (55.2%) of the latter were admitted to the ICU. Sepsis accounted for 51.5% of the growth in volume of ICU admissions among SLE hospitalizations during the study period. Among ICU admissions with sepsis, 25.3% were aged ≥ 65 years, 88.6% were female, and 64.4% were non-white minorities. The odds of short-term mortality among septic ICU admissions were increased among those lacking health insurance (adjusted odds ratio 1.40 [95% confidence interval 1.07–1.84]), while being unaffected by gender and race/ethnicity, and remaining unchanged over the study period. On adjusted analyses among ICU admissions, the short-term mortality among those with and without sepsis was 13% (95% CI 12.6–13.3) and 2.7% (95% CI 2.6–2.8), respectively. Sepsis was associated with 63.6% of all short-term mortality events.

Conclusions

Sepsis is a major, incremental driver of the demand for critical care services among SLE hospitalizations. Despite its relatively low mortality, sepsis was associated with most of the short-term deaths among ICU patients with SLE.

ICU Survivors Have a Substantial Higher Risk of Developing New Chronic Conditions Compared to a Population-Based Control Group

OBJECTIVES

To describe the types and prevalence of chronic conditions in an ICU population and a population-based control group during the year before ICU admission and to quantify the risk of developing new chronic conditions in ICU patients compared with the control group.

DESIGN

We conducted a retrospective cohort study, combining a national health insurance claims database and a national quality registry for ICUs. Claims data in the timeframe 2012-2014 were combined with clinical data of patients who had been admitted to an ICU during 2013. To assess the differences in risk of developing new chronic conditions, ICU patients were compared with a population-based control group using logistic regression modeling.

SETTING

Eighty-one Dutch ICUs.

PATIENTS

All patients admitted to an ICU during 2013. A population-based control group was created, and weighted on the age, gender, and socio-economic status of the ICU population.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

ICU patients (n = 56,760) have more chronic conditions compared with the control group (n = 75,232) during the year before ICU admission (p < 0.0001). After case-mix adjustment ICU patients had a higher risk of developing chronic conditions, with odds ratios ranging from 1.67 (CI, 1.29-2.17) for asthma to 24.35 (CI, 14.00-42.34) for epilepsy, compared with the control group.

CONCLUSIONS

Due to the high prevalence of chronic conditions and the increased risk of developing new chronic conditions, ICU follow-up care is advised and may focus on the identification and treatment of the new developed chronic conditions.

Potentially Preventable Intensive Care Unit Admissions in the United States, 2006-2015

Rationale: Increasing intensive care unit (ICU) beds and the critical care workforce are often advocated to address an aging and increasingly medically complex population. However, reducing potentially preventable ICU stays may be an alternative to ensure adequate capacity.Objectives: To determine the proportions of ICU admissions meeting two definitions of being potentially preventable using nationally representative U.S. claims databases.Methods: We analyzed claims from 2006 to 2015 from all Medicare Fee-for-Service (FFS) beneficiaries and from a large national payer offering a private insurance (PI) plan and a Medicare Advantage (MA) plan. Potentially preventable hospitalizations were identified using existing definitions for ambulatory care sensitive conditions (ACSCs) and life-limiting malignancies (LLMs).Results: We analyzed 420,369,434 person-years of insurance coverage, during which there were 99,793,416 acute inpatient hospitalizations, of which 16,646,977 (16.7%) were associated with an ICU admission. Of these, the proportions with an ACSC were 12.9%, 12.7%, and 15.8%, and with an LLM were 5.2%, 5.4%, and 6.4%, among those with PI, MA, and FFS, respectively. Over 10 years, the absolute percentages of ACSC-associated ICU stays declined (PI = -1.1%, MA -6.4%, FFS -6.4%; all P < 0.001 for all trends). Smaller changes were noted among LLM-associated ICU stays, declining in the MA cohort (-0.8%) and increasing in the FFS (+0.3%) and PI (+0.2%) populations (P < 0.001 for all trends).Conclusions: An appreciable proportion of U.S. ICU admissions may be preventable with community-based interventions. Investment in the outpatient infrastructure required to prevent these ICU admissions should be considered as a complementary, if not alternative, strategy to expanding ICU capacity to meet future demand.

Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020

BACKGROUND

Indian Society of Critical Care Medicine (ISCCM) guidelines on Planning and Designing Intensive care (ICU) were first developed in 2001 and later updated in 2007. These guidelines were adopted in India, many developing Nations and major Institutions including NABH. Various international professional bodies in critical care have their own position papers and guidelines on planning and designing of ICUs; being the professional body of intensivists in India ISCCM therefore addresses the subject in contemporary context relevant to our clinical practice, its variability according to specialty and subspecialty, quality, resource limitation, size and location of the institution. Aim: To have a consensus document reflecting the philosophy of ISCCM to deliver safe & quality Critical Care in India, taking into consideration the requirement of regulatory agencies (national & international) and need of people at large, including promotion of training, education and skill upgradation. It also aiming to promote leadership and development and managerial skill among the critical care team. Material and Methods: Extensive review of literature including search of databases in English language, resources of regulatory bodies, guidelines and recommendations of international critical care societies. National Survey of ISCCM members and experts to understand their viewpoints on respective issues. Visiting of different types and levels of ICUs by team members to understand prevailing practices, aspiration and Challenges. Several face to face meetings of the expert committee members in big and small groups with extensive discussions, presentations, brain storming and development of initial consensus draft. Discussion on draft through video conferencing, phone calls, Emails circulations, one to one discussion Result: Based upon extensive review, survey and input of experts' ICUs were categorized in to three levels suitable in Indian setting. Level III ICUs further divided into sub category A and B. Recommendations were grouped in to structure, equipment and services of ICU with consideration of variation in level of ICU of different category of hospitals. Conclusion: This paper summarizes consensus statement of various aspect of ICU planning and design. Defined mandatory and desirable standards of all level of ICUs and made recommendations regarding structure and layout of ICUs. Definition of intensive care and intensivist, planning for strength of ICU and requirement of manpower were also described.

HOW TO CITE THIS ARTICLE

Rungta N, Zirpe KG, Dixit SB, Mehta Y, Chaudhry D, Govil D, et al. Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020. Indian J Crit Care Med 2020;24(Suppl 1):S43-S60.

Impact of mechanical ventilation on the daily costs of ICU care: a systematic review and meta regression

The impact of mechanical ventilation on the daily costs of intensive care unit (ICU) care is largely unknown. We thus conducted a systematic search for studies measuring the daily costs of ICU stays for general populations of adults (age ≥18 years) and the added costs of mechanical ventilation. The relative increase in the daily costs was estimated using random effects meta regression. The results of the analyses were applied to a recent study calculating the excess length-of-stay associated with ICU-acquired (ventilator-associated) pneumonia, a major complication of mechanical ventilation. The search identified five eligible studies including a total of 54 766 patients and ~238 037 patient days in the ICU. Overall, mechanical ventilation was associated with a 25.8% (95% CI 4.7%–51.2%) increase in the daily costs of ICU care. A combination of these estimates with standardised unit costs results in approximate daily costs of a single ventilated ICU day of €1654 and €1580 in France and Germany, respectively. Mechanical ventilation is a major driver of ICU costs and should be taken into account when measuring the financial burden of adverse events in ICU settings.

Structure of the Anesthesia Intensive Care Units: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

BACKGROUND AND OBJECTIVE

In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency.

MATERIALS AND METHOD

Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus.

RESULTS

The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus.

CONCLUSIONS

The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units.

Concurrent Types of Intracranial Hemorrhage are Associated with a Higher Mortality Rate in Adult Patients with Traumatic Subarachnoid Hemorrhage: A Cross-Sectional Retrospective Study

Traumatic subarachnoid hemorrhage (SAH) is the second most frequent intracranial hemorrhage and a common radiologic finding in computed tomography. This study aimed to estimate the risk of mortality in adult trauma patients with traumatic SAH concurrent with other types of intracranial hemorrhage, such as subdural hematoma (SDH), epidural hematoma (EDH), and intracerebral hemorrhage (ICH), compared to the risk in patients with isolated traumatic SAH. We searched our hospital’s trauma database from 1 January, 2009 to 31 December, 2018 to identify hospitalized adult patients ≥20 years old who presented with a trauma abbreviated injury scale (AIS) of ≥3 in the head region. Polytrauma patients with an AIS of ≥3 in any other region of the body were excluded. A total of 1856 patients who had SAH were allocated into four exclusive groups: (Group I) isolated traumatic SAH, n = 788; (Group II) SAH and one diagnosis, n = 509; (Group III) SAH and two diagnoses, n = 493; and (Group IV) SAH and three diagnoses, n = 66. One, two, and three diagnoses indicated occurrences of one, two, or three other types of intracranial hemorrhage (SDH, EDH, or ICH). The adjusted odds ratio with a 95% confidence interval (CI) of the level of mortality was calculated with logistic regression, controlling for sex, age, and pre-existing comorbidities. Patients with isolated traumatic SAH had a lower rate of mortality (1.8%) compared to the other three groups (Group II: 7.9%, Group III: 12.4%, and Group IV: 27.3%, all p < 0.001). When controlling for sex, age, and pre-existing comorbidities, we found that Group II, Group III, and Group IV patients had a 4.0 (95% CI 2.4–6.5), 8.9 (95% CI 4.8–16.5), and 21.1 (95% CI 9.4–47.7) times higher adjusted odds ratio for mortality, respectively, than the patients with isolated traumatic SAH. In this study, we demonstrated that compared to patients with isolated traumatic SAH, traumatic SAH patients with concurrent types of intracranial hemorrhage have a higher adjusted odds ratio for mortality.

Herpes Simplex Virus Encephalitis: Patterns of Epidemiology and Outcomes of Patients Admitted to the Intensive Care Unit in Texas, 2008 - 2016

Background

Patients with herpes simplex virus encephalitis (HSVE) often require admission to the intensive care unit (ICU) and have considerably worse outcomes than those not critically ill. The short-term outcomes of critically ill patients in the general population have markedly improved over the past decades. However, the population-level patterns of demand for critical care services among patients with HSVE have not been examined, and it is unknown whether there were corresponding outcome gains among those admitted to the ICU.

Methods

The Texas Inpatient Public Use Data File was used to identify hospitalizations with HSVE aged ≥ 18 years during 2008 - 2016. ICU admissions were identified using unit-specific revenue codes. The patterns of ICU utilization and those of short-term outcomes (with short-term mortality defined as in-hospital death or discharge to hospice) were examined across demographic strata and over time.

Results

Among 1,964 hospitalizations with HSVE, 1,176 (59.9%) were admitted to ICU (45.8% aged ≥ 65 years; 53.1% female, among ICU admissions). ICU utilization increased with age (from 47.9% (age 18 - 44 years) through 61.2% (older adults (age ≥ 65 years)); P = 0.0003 for trend), and increased over time only among older adults (odds ratio: 1.06/year (95% confidence interval (CI): 1.01 - 1.12)). Among ICU admissions, routine home discharge, transfer to a post-acute care facility, and short-term mortality occurred in 26.8%, 39.5%, and 18.7%, respectively; the corresponding outcomes for older adults were 10.6%, 51.4%, and 26.2%, respectively. The outcomes for the whole cohort of ICU admissions remained unchanged over time.

Conclusions

Adults with HSVE had high demand for critical care services, and those admitted to ICU had high short-term mortality and substantial residual morbidity among survivors, which remained unchanged over time. These findings can inform clinicians’ decision-making and discussions about goals of care with affected patients and their surrogates.

Estimating ICU Benefit: A Randomized Study of Physicians

OBJECTIVES

The distinction between overuse and appropriate use of the ICU hinges on whether a patient would benefit from ICU care. We sought to test 1) whether physicians agree about which types of patients benefit from ICU care and 2) whether estimates of ICU benefit are influenced by factors unrelated to severity of illness.

DESIGN

Randomized study.

SETTING

Online vignettes.

SUBJECTS

U.S. critical care physicians.

INTERVENTIONS

Physicians were provided with eight vignettes of hypothetical patients. Each vignette had a single patient or hospital factor randomized across participants (four factors related and four unrelated to severity of illness).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the estimate of ICU benefit, assessed with a 4-point Likert-type scale. In total, 1,223 of 8,792 physicians volunteered to participate (14% recruitment rate). Physician agreement of ICU benefit was poor (mean intraclass correlation coefficient for each vignette: 0.06; range: 0-0.18). There were no vignettes in which more than two thirds of physicians agreed about the extent to which a patient would benefit from ICU care. Increasing severity of illness resulted in greater estimated benefit of ICU care. Among factors unrelated to severity of illness, physicians felt ICU care was more beneficial when told one ICU bed was available than if ICU bed availability was unmentioned. Physicians felt ICU care was less beneficial when family was present than when family presence was unmentioned. The patient's age, but not race/ethnicity, also impacted estimates of ICU benefit.

CONCLUSIONS

Estimates of ICU benefit are widely dissimilar and influenced by factors unrelated to severity of illness, potentially resulting in inconsistent allocation of ICU care.