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Andersen SK, Gamble N, Rewa O. COVID-19 critical care triage across Canada: a narrative synthesis and ethical analysis of early provincial triage protocols. Can J Anaesth 2024; 71:1126-1136. [PMID: 38589739 PMCID: PMC11269410 DOI: 10.1007/s12630-024-02744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 12/23/2023] [Accepted: 01/10/2024] [Indexed: 04/10/2024] Open
Abstract
PURPOSE The COVID-19 pandemic created conditions of scarcity that led many provinces within Canada to develop triage protocols for critical care resources. In this study, we sought to undertake a narrative synthesis and ethical analysis of early provincial pandemic triage protocols. METHODS We collected provincial triage protocols through personal correspondence with academic and political stakeholders between June and August 2020. Protocol data were extracted independently by two researchers and compared for accuracy and agreement. We separated data into three categories for comparative content analysis: protocol development, ethical framework, and protocol content. Our ethical analysis was informed by a procedural justice framework. RESULTS We obtained a total of eight provincial triage protocols. Protocols were similar in content, although age, physiologic scores, and functional status were variably incorporated. Most protocols were developed through a multidisciplinary, expert-driven, consensus process, and many were informed by influenza pandemic guidelines previously developed in Ontario. All protocols employed tiered morality-focused exclusion criteria to determine scarce resource allocation at the level of regional health care systems. None included a public engagement phase, although targeted consultation with public advocacy groups and relevant stakeholders was undertaken in select provinces. Most protocols were not publicly available in 2020. CONCLUSIONS Early provincial COVID-19 triage protocols were developed by dedicated expert committees under challenging circumstances. Nonetheless, few were publicly available, and public consultation was limited. No protocols were ever implemented, including during periods of extreme critical care surge. A national approach to pandemic triage that incorporates additional aspects of procedural justice should be considered in preparation for future pandemics.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, AB, T6G 2G3, Canada.
- Alberta Health Services, Edmonton, AB, Canada.
| | - Nathan Gamble
- Alberta Health Services, Edmonton, AB, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Oleksa Rewa
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Mendlovic J, Mimouni FB. Census-Dependent Mortality of Ventilated Patients With COVID-19 in Israel: Noninterventional Observational Cohort Study. Interact J Med Res 2024; 13:e41749. [PMID: 38981116 PMCID: PMC11267089 DOI: 10.2196/41749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 12/06/2023] [Accepted: 05/20/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic led to several surges in the mass hospitalization rate. Extreme increases in hospital admissions without adequate medical resources may increase mortality. No study has addressed the impact of daily census of ventilated patients on mortality in the context of the pandemic in a nationwide setting. OBJECTIVE This study aimed to determine whether daily census of ventilated patients affected COVID-19 mortality rates nationwide in Israel. METHODS We conducted a cohort study using nationwide, public-domain, population-based COVID-19 data of hospitalized patients from an Israeli database from March 11, 2020, until February 11, 2021. We included all COVID-19 hospital admissions, classified as mild to severe per the Centers for Diseases Control and Prevention classification irrespective of whether they were mechanically ventilated. Outcome measures were daily death rates and death rates expressed as a percentage of ventilated patients. RESULTS During the study period (338 days from March 11, 2020, to February 11, 2021), 715,743 patients contracted and were clinically confirmed as having COVID-19. Among them, 5577 (0.78%) patients died. In total, 3398 patients were ventilated because of severe COVID-19. Daily mortality correlated with daily census of ventilated patients (R2=0.828, P<.001). The daily percent mortality of ventilated patients also correlated with the daily census of ventilated patients (R2=0.365, P<.001)-backward multiple regression analysis demonstrated that this positive correlation was still highly significant even when correcting for the average age or gender of ventilated patients (R2=0.4328, P<.001) or for the surge in their number. Overall, 40% of the variation in mortality was explained by variations in the daily census of ventilated patients. ANOVA revealed that at less than 50 ventilated patients per day, the daily mortality of ventilated patients was slightly above 5%, and it nearly doubled (10%) with 50-149 patients; moreover, in all categories of ≥200 patients ventilated per day, it more than tripled at ≥15% (P<.001). CONCLUSIONS Daily mortality rates per ventilated patient increased with an increase in the number of ventilated patients, suggesting the saturation of medical resources. Policy makers should be aware that expanding medical services without adequate resources may increase mortality. Governments should perform similar analyses to provide indicators of system saturation, although further validation of these results might be needed to use this indicator to drive public policy.
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Affiliation(s)
- Joseph Mendlovic
- Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
- Associate Director General Office, Israel Ministry of Health, Jerusalem, Israel
| | - Francis B Mimouni
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Leumit Health Service, Tel Aviv, Israel
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Karwa ML, Naqvi AA, Betchen M, Puri AK. In-Hospital Triage. Crit Care Clin 2024; 40:533-548. [PMID: 38796226 DOI: 10.1016/j.ccc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.
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Affiliation(s)
- Manoj L Karwa
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Weiler Hospital, 4th Floor, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Ali Abbas Naqvi
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Melanie Betchen
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Ajay Kumar Puri
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
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Li W, Lin X, Fang Z, Fang X, Zheng X, Tu W, Feng X. Risk factors for converting traditional wards to temporary intensive care units during the COVID-19 pandemic: Insights from nurses' perspectives. Nurs Crit Care 2024. [PMID: 38924665 DOI: 10.1111/nicc.13106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The surge in critically ill COVID-19 patients caused a shortage of intensive care unit (ICU) beds. Some hospitals temporarily transformed general wards into ICUs to meet this pressing health care demand. AIM This study aims to evaluate and analyse the risk factors in temporary ICU from the perspective of nurses. By identifying these factors, the goal is to provide actionable insights and recommendations for effectively establishing and managing temporary ICUs in similar crisis scenarios in the future. STUDY DESIGN The study was conducted in China within a public hospital. Specifically, it focused on examining 62 nurses working in a temporary ICU that was converted from an infectious disease ward. The research utilized the Hazard Vulnerability Analysis (HVA) scoring method to identify potential threats, evaluate their probability, estimate their impact on specific organizations or regions and calculate the relative risk associated with such occurrences. RESULTS Staff demonstrated the highest risk percentage (32.74%), with Stuff (16.11%), Space (15.19%) and System (11.30%) following suit. The most critical risk factors included insufficient knowledge and decision-making competence in critical care (56.14%), lacking decision-making abilities and skills in renal replacement therapy care (55.37%), inadequate decision-making capacity and relevant skills in respiratory support care (50.64%), limited decision-making capability in circulatory support care (45.73%) and unfamiliarity with work procedures or systems (42.09%). CONCLUSIONS Urgent implementation of tailored training and support for temporary ICU nurses is paramount. Addressing capability and skill-related issues among these nurses supersedes resource availability, infrastructure, equipment and system considerations. Essential interventions must target challenges encompassing nurses' inability to perform critical treatment techniques autonomously and ensure standardized care. These measures are designed to heighten patient safety and elevate care quality during emergencies. These findings offer a viable avenue to mitigate potential moral distress, anxiety and depression among nurses, particularly those transitioning from non-critical care backgrounds. These nurses swiftly assimilate into temporary ICUs, and the study's insights offer practical guidance to alleviate their specific challenges. RELEVANCE TO CLINICAL PRACTICE The study on risk factors for converting traditional wards into temporary ICU during the COVID-19 pandemic, especially from the perspective of nurses, provides crucial insights into the challenges and requirements for effectively establishing and managing these emergency settings. The findings highlight several key areas of concern and opportunities for improvement directly related to clinical practice, particularly in situations where there is a rapid need to adapt to increased demands for critical care. By addressing the identified risk factors through enhanced training, support systems, resource management, process improvements and cultivating a culture of adaptability, not only can the quality of care in temporary ICUs be improved, but also can the health care system be better prepared for future emergencies. These actions will help mitigate the risks associated with such conversions, ultimately benefiting patient safety, staff well-being and the overall effectiveness of health care services in crises.
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Affiliation(s)
- Wenyu Li
- Nursing Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiuli Lin
- Infectious Diseases Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenhong Fang
- Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xufei Fang
- General Surgery Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiuyun Zheng
- Nursing Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenyu Tu
- Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaofang Feng
- Nursing Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Douillet D, Riou J, Morin F, Mahieu R, Chauvin A, Gennai S, Ferrant L, Lopez R, Sebbane M, Plantefeve G, Brice C, Cayeux C, Savary D, Moumneh T, Penaloza A, Roy PM. Derivation and validation of a risk-stratification model for patients with probable or proven COVID-19 in EDs: the revised HOME-CoV score. Emerg Med J 2024; 41:218-225. [PMID: 38365436 DOI: 10.1136/emermed-2022-212631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND The HOME-CoV (Hospitalisation or Outpatient ManagEment of patients with SARS-CoV-2 infection) score is a validated list of uniquely clinical criteria indicating which patients with probable or proven COVID-19 can be treated at home. The aim of this study was to optimise the score to improve its ability to discriminate between patients who do and do not need admission. METHODS A revised HOME-CoV score was derived using data from a previous prospective multicentre study which evaluated the original Home-CoV score. Patients with proven or probable COVID-19 attending 34 EDs in France, Monaco and Belgium between April and May 2020 were included. The population was split into a derivation and validation sample corresponding to the observational and interventional phases of the original study. The main outcome was non-invasive or invasive ventilation or all-cause death within 7 days following inclusion. Two threshold values were defined using a sensitivity of >0.9 and a specificity of >0.9 to identify low-risk and high-risk patients, respectively. The revised HOME-CoV score was then validated by retrospectively applying it to patients in the same EDs with proven or probable COVID-19 during the interventional phase. The revised HOME-CoV score was also tested against original HOME-CoV, qCSI, qSOFA, CRB65 and SMART-COP in this validation cohort. RESULTS There were 1696 patients in the derivation cohort, of whom 65 (3.8%) required non-invasive ventilation or mechanical ventilation or died within 7 days and 1304 patients in the validation cohort, of whom 22 (1.7%) had a progression of illness. The revised score included seven clinical criteria. The area under the curve (AUC) was 87.6 (95% CI 84.7 to 90.6). The cut-offs to define low-risk and high-risk patients were <2 and >3, respectively. In the validation cohort, the AUC was 85.8 (95% CI 80.6 to 91.0). A score of <2 qualified 73% of patients as low risk with a sensitivity of 0.77 (0.55-0.92) and a negative predictive value of 0.99 (0.99-1.00). CONCLUSION The revised HOME-CoV score, which does not require laboratory testing, may allow accurate risk stratification and safely qualify a significant proportion of patients with probable or proven COVID-19 for home treatment.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, CHU Angers, University of Angers, CHU Angers, Angers, France
- UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, University of Angers; FCRIN, INNOVTE, Universite Angers Faculte des sciences, Angers, France
| | - Jérémie Riou
- Micro et Nano médecines Translationnelles, MINT, UNIV Angers, UMR INSERM 1066, UMR CNRS 6021, CHU Angers, Angers, France
- Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, Université Angers Faculté des Sciences, Angers, France
| | - François Morin
- Emergency Department, CHU Angers, University of Angers, CHU Angers, Angers, France
| | - Rafaël Mahieu
- Department of Infectious Disease, Angers University Hospital; University of Angers, CHU Angers, Angers, France
- CRCINA, Inserm U1232, University of Nantes-Angers, Universite Angers Faculte Des Sciences, Angers, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Stéphane Gennai
- Emergency Department, Reims University Hospital, University Hospital Centre Reims, Reims, France
- UFR Médecine, Université de Reims Champagne-Ardenne, Reims, France
| | - Lionel Ferrant
- Emergency Department, Université catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Raphaëlle Lopez
- Emergency Department, Sart Tilman University Hospital, Centre hospitalier universitaire de Liège, Liege, Belgium
| | - Mustapha Sebbane
- Emergency Department, Montpellier University Hospital, Montpellier, France
| | | | - Christian Brice
- Emergency Department, Centre Hospitalier de Saint Brieuc, Saint Brieuc, France
| | - Coralie Cayeux
- Emergency Department, Centre Hospitalier de Remiremont, Remiremont, France
| | - Dominique Savary
- Department of Emergency Medicine, University of Angers, ANGERS, France
- Inserm IRSET UMR_S1085, I, EHESP, Angers, France
| | | | - Andrea Penaloza
- Emergency, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Pierre Marie Roy
- Emergency Department, CHU Angers, University of Angers, CHU Angers, Angers, France
- UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, University of Angers; FCRIN, INNOVTE, Universite Angers Faculte des sciences, Angers, France
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Zwerwer LR, Kloka J, van der Pol S, Postma MJ, Zacharowski K, van Asselt ADI, Friedrichson B. Mechanical ventilation as a major driver of COVID-19 hospitalization costs: a costing study in a German setting. HEALTH ECONOMICS REVIEW 2024; 14:4. [PMID: 38227207 PMCID: PMC10790444 DOI: 10.1186/s13561-023-00476-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/21/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND While COVID-19 hospitalization costs are essential for policymakers to make informed health care resource decisions, little is known about these costs in western Europe. The aim of the current study is to analyze these costs for a German setting, track the development of these costs over time and analyze the daily costs. METHODS Administrative costing data was analyzed for 598 non-Intensive Care Unit (ICU) patients and 510 ICU patients diagnosed with COVID-19 at the Frankfurt University hospital. Descriptive statistics of total per patient hospitalization costs were obtained and assessed over time. Propensity scores were estimated for length of stay (LOS) at the general ward and mechanical ventilation (MV) duration, using covariate balancing propensity score for continuous treatment. Costs for each additional day in the general ward and each additional day in the ICU with and without MV were estimated by regressing the total hospitalization costs on the LOS and the presence or absence of several treatments using generalized linear models, while controlling for patient characteristics, comorbidities, and complications. RESULTS Median total per patient hospitalization costs were €3,010 (Q1 - Q3: €2,224-€5,273), €5,887 (Q1 - Q3: €3,054-€10,879) and €21,536 (Q1 - Q3: €7,504-€43,480), respectively, for non-ICU patients, non-MV and MV ICU patients. Total per patient hospitalization costs for non-ICU patients showed a slight increase over time, while total per patient hospitalization costs for ICU patients decreased over time. Each additional day in the general ward for non-ICU COVID-19 patients costed €463.66 (SE: 15.89). Costs for each additional day in the general ward and ICU without and with mechanical ventilation for ICU patients were estimated at €414.20 (SE: 22.17), €927.45 (SE: 45.52) and €2,224.84 (SE: 70.24). CONCLUSIONS This is, to our knowledge, the first study examining the costs of COVID-19 hospitalizations in Germany. Estimated costs were overall in agreement with costs found in literature for non-COVID-19 patients, except for higher estimated costs for mechanical ventilation. These estimated costs can potentially improve the precision of COVID-19 cost effectiveness studies in Germany and will thereby allow health care policymakers to provide better informed health care resource decisions in the future.
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Affiliation(s)
- Leslie R Zwerwer
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Center for Information Technology, University of Groningen, Groningen, The Netherlands.
| | - Jan Kloka
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Simon van der Pol
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Health-Ecore, Zeist, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Health-Ecore, Zeist, The Netherlands
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Antoinette D I van Asselt
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Benjamin Friedrichson
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Chung E, Chung KS, Leem AY, Woo A, Park MS, Kim YS, Lee SH. Impact of age on mortality and transfer to long-term care in patients in an intensive care unit. BMC Geriatr 2023; 23:839. [PMID: 38087191 PMCID: PMC10714659 DOI: 10.1186/s12877-023-04526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND In the global trend of population aging, age is one of the significant factors to be considered in critically ill patients. However, the impact of age on clinical outcomes and long-term prognosis in this population varies across different studies. METHODS We conducted a retrospective cohort analysis for patients admitted to the medical intensive care unit (ICU) (30 beds) between January 2017 and December 2020 at the tertiary referral hospital in Korea. Patients were classified into three groups according to age: <65 years, old age (65-79 years), and very old age (≥ 80 years). Subsequently, enrolled patients were analyzed for acute mortality and long-term prognosis. RESULTS Among the 1584 patients, the median age was 67.0 (57.0-76.0) years, and 65.2% were male. Median ICU length of stay (LOS) (8, 9, and 10 days in < 65, 65-79, and ≥ 80 years, respectively; p = 0.006) and the proportion of patients who were transferred to long-term care hospital at the time of discharge (12.9% vs. 28.3% vs. 39.4%, respectively; p < 0.001) increased with age. Multivariable logistic analysis showed no significant difference in the 28-day mortality in the old age (adjusted odds ratio [aOR] 0.88; 95% confidence interval [CI] 0.65-1.17) and very old age (aOR 1.05; 95% CI 0.71-1.55) groups compared to that in patients with age < 65 years. However, the relevance of the proportion of ICU LOS ≥ 7 days and transfers to other hospitals after discharge increased with age. CONCLUSIONS Age did not affect acute mortality in critical illness patients. However, surviving older age groups required more long-term care facilities compared to patients younger than 65 years after acute management. These results indicate that in an aging society, the importance of not only acute management but also long-term care facilities may increase for critical illness patients.
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Affiliation(s)
- Eunki Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ala Woo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Su Hwan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Mitchell SH, Taylor MJ, Paulsen M, Morris SC. The Statewide Patient Load Balancing Work of Washington State's Medical Operations Coordination Center. Disaster Med Public Health Prep 2023; 17:e556. [PMID: 38059280 DOI: 10.1017/dmp.2023.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Load balancing of constrained healthcare resources has become a critical aspect of assuring access to care during periods of pandemic related surge. These impacts include patient surges, staffing shortages, and limited access to specialty resources. This research focuses on the creation and work of a novel statewide coordination center, the Washington Medical Coordination Center (WMCC), whose primary goal is the load balancing of patients across the healthcare continuum of Washington State. METHODS This article discusses the origins, development, and operations of the WMCC including key partners, cooperative agreements, and structure necessary to create a patient load balancing system on a statewide level. RESULTS As of April 21, 2022, the WMCC received 3821 requests from Washington State hospitals. Nearly 90% were received during the pandemic surge. Nearly 75% originated from rural hospitals that are most often limited in their ability to transfer patients when referral centers are also overwhelmed. CONCLUSIONS The WMCC served as an effective tool to carry out patient load balancing activities during the COVID-19 pandemic surge in Washington State. It (the WMCC) has been shown to be an equity enhancing, cost effective means of managing healthcare surge events across a broad geographic region.
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Affiliation(s)
- Steven H Mitchell
- Washington Medical Coordination Center, University of Washington, Department of Emergency Medicine, Seattle, WA
| | - Mark J Taylor
- Washington Medical Coordination Center, Harborview Medical Center, Seattle, WA
| | - Maria Paulsen
- Washington Medical Coordination Center, Harborview Medical Center, Seattle, WA
| | - Stephen C Morris
- Washington Medical Coordination Center, University of Washington, Department of Emergency Medicine, Seattle, WA
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Garber S, Brunner JO, Heller AR, Marckmann G, Bartenschlager CC. Simulation of the mortality after different ex ante (secondary) and ex post (tertiary) triage methods in people with disabilities and pre-existing diseases. DIE ANAESTHESIOLOGIE 2023; 72:10-18. [PMID: 37733034 PMCID: PMC10692011 DOI: 10.1007/s00101-023-01336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
The significant increase in patients during the COVID-19 pandemic presented the healthcare system with a variety of challenges. The intensive care unit is one of the areas particularly affected in this context. Only through extensive infection control measures as well as an enormous logistical effort was it possible to treat all patients requiring intensive care in Germany even during peak phases of the pandemic, and to prevent triage even in regions with high patient pressure and simultaneously low capacities. Regarding pandemic preparedness, the German Parliament passed a law on triage that explicitly prohibits ex post (tertiary) triage. In ex post triage, patients who are already being treated are included in the triage decision and treatment capacities are allocated according to the individual likelihood of success. Legal, ethical, and social considerations for triage in pandemics can be found in the literature, but there is no quantitative assessment with respect to different patient groups in the intensive care unit. This study addressed this gap and applied a simulation-based evaluation of ex ante (primary) and ex post triage policies in consideration of survival probabilities, impairments, and pre-existing conditions. The results show that application of ex post triage based on survival probabilities leads to a reduction in mortality in the intensive care unit for all patient groups. In the scenario close to a real-world situation, considering different impaired and prediseased patient groups, a reduction in mortality of approximately 15% was already achieved by applying ex post triage on the first day. This mortality-reducing effect of ex post triage is further enhanced as the number of patients requiring intensive care increases.
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Affiliation(s)
- Sara Garber
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
| | - Jens O Brunner
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
- Professor of Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Lyngby, Denmark
| | - Axel R Heller
- Clinic for Anaesthesiology and Operative Intensive Care, Medical Faculty, University Hospital of Augsburg, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Georg Marckmann
- Institute for Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Lessingstr. 2, 80336, Munich, Germany
| | - Christina C Bartenschlager
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
- Professor of Applied Data Science in Healthcare, Nürnberg School of Health, Klinikum Nürnberg and Ohm University of Applied Sciences Nuremberg, Keßlerplatz 12, Nuremberg, Germany
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Maves RC. Measuring Strain in the ICU. Crit Care Med 2023; 51:1812-1814. [PMID: 37971333 DOI: 10.1097/ccm.0000000000006012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Ryan C Maves
- Sections of Infectious Diseases and Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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11
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Jackson BM, Wynia MK. Spheres of Morality: Is There a Point? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:5-7. [PMID: 38010666 DOI: 10.1080/15265161.2023.2274267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Brian M Jackson
- University of Colorado School of Medicine
- University of Colorado Center for Bioethics and Humanities
| | - Matthew K Wynia
- University of Colorado School of Medicine
- University of Colorado Center for Bioethics and Humanities
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12
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Al Bazroun MI, Almahrouq A. A Nursing Care Model for Surge Capacity Management in Intensive Care Units During the COVID-19 Pandemic: Experience From Qatif Central Hospital, Saudi Arabia. Cureus 2023; 15:e48193. [PMID: 38050496 PMCID: PMC10693669 DOI: 10.7759/cureus.48193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 12/06/2023] Open
Abstract
Introduction The COVID-19 pandemic resulted in a surge of critically ill patients requiring intensive care. This posed challenges for healthcare systems in managing increased ICU bed demands with limited resources. Methods A retrospective qualitative review of institutional documents and plans was conducted. Key strategies related to ICU bed expansion, nursing staff classification and training, clinical supervision, and performance evaluation were analyzed. Results Qatif Central Hospital increased ICU beds from 20 to 50 by converting other clinical areas. Nursing staff were categorized based on critical care experience, and additional training was provided to non-ICU nurses. A preceptor-led nursing care model with staff responsibilities was implemented. Periodic evaluations ensured continued competence. Conclusion The nursing care model at Qatif Central Hospital effectively facilitated ICU surge capacity while maintaining care quality. The model offers a viable framework for other healthcare institutions facing similar challenges. However, the study is limited by its retrospective design and focus on a single institution.
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Koraishy FM, Mallipattu SK. Dialysis resource allocation in critical care: the impact of the COVID-19 pandemic and the promise of big data analytics. FRONTIERS IN NEPHROLOGY 2023; 3:1266967. [PMID: 37965069 PMCID: PMC10641281 DOI: 10.3389/fneph.2023.1266967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/05/2023] [Indexed: 11/16/2023]
Abstract
The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.
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Affiliation(s)
- Farrukh M. Koraishy
- Division of Nephrology, Department of Medicine, Stony Brook University Hospital, , Stony Brook, NY, United States
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14
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Engrand N, Sene T, Caputo G, Sabben C, Gregoire C, Blanc R, Aldea S, Chauvet D, Vo-Thanh S, Teissier S, Versace N, Rohou L, Piotin M, Gueguen A. Ethical Management of COVID-19 Pandemic at a Neurological Hospital: The Ethicovid Report. J Neurosurg Anesthesiol 2023; 35:417-422. [PMID: 35543619 DOI: 10.1097/ana.0000000000000849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/30/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND During the first wave of the coronavirus disease-2019 (COVID-19) pandemic, it was necessary to prepare for the possibility of triaging patients who could benefit from access to an intensive care unit (ICU). In our neuroscience institution, the challenge was to continue to manage usual neurological emergencies as well as the influx of COVID-19 patients. METHODS We report the experience of an ethical consulting unit to support care clinical decisions during the first wave of the pandemic (March 16 to April 30, 2020). Three objective evaluation criteria were defined: 2 of these criteria, patient's factors and general disease severity (Simplified Acute Physiology Score II), were common to all patients, and the third was the specific severity of the disease (neurological for brain injury, respiratory for COVID-19). Given our scarce resources, we used a high probability of a 3-month modified Rankin Scale ≤3 as the criterion for further resuscitation and management. RESULTS A total of 295 patients were admitted during the first pandemic wave; 111 with COVID-19 and 184 with neurological emergencies. The ethical unit's expertise was sought for 75 clinical situations in 56 patients (35 COVID-19 and 21 neurological). Decisions were as follows: 11% no limitation on care, 5% expectant care with reassessment (maximum therapy to assess possible progress pending decision), 67% partial limitation (no intensification of care or no transfer to ICU), and 17% limitation of curative care. At no time did a lack of availability of ICU beds require the ethical unit to advise against admission to the ICU. CONCLUSIONS Our ethical consulting unit allowed for collegial ethical decision-making in line with international recommendations. This model could be easily transferred to other triage situations, provided it is adapted to the local context.
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Affiliation(s)
- Nicolas Engrand
- Intensive Care Unit-Anesthesiology/Mobile Palliative Care Team
| | | | | | | | | | | | - Sorin Aldea
- Neurosurgery, Rothschild Foundation Hospital
| | | | - Sophie Vo-Thanh
- Intensive Care Unit-Anesthesiology/Mobile Palliative Care Team
| | | | - Nathalie Versace
- Department of Neuroscience, Rothschild Foundation Hospital, Paris, France
| | - Léa Rohou
- Intensive Care Unit-Anesthesiology/Mobile Palliative Care Team
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15
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Davis CL, Bjoring M, Hursh J, Smith S, Blevins C, Blackstone K, Nicholson E, Hoke T, Michel J, Noth I, Barros A, Enfield K. The Intensive Care Unit Bundle Board: A Novel Real-Time Data Visualization Tool to Improve Maintenance Care for Invasive Catheters. Appl Clin Inform 2023; 14:892-902. [PMID: 37666277 PMCID: PMC10651369 DOI: 10.1055/a-2165-5861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Critically ill patients are at greater risk of healthcare-associated infections (HAIs). The use of maintenance bundles helps to reduce this risk but also generates a rapid accumulation of complex data that is difficult to aggregate and subsequently act upon. OBJECTIVES We hypothesized that a digital display summarizing nursing documentation of invasive catheters (including central venous access devices, arterial catheters, and urinary catheters) would improve invasive device maintenance care and documentation. Our secondary objectives were to see if this summary would reduce the duration of problematic conditions, that is, characteristics associated with increased risk of infection. METHODS We developed and implemented a data visualization tool called the "Bundle Board" to display nursing observations on invasive devices. The intervention was studied in a 28-bed medical intensive care unit (MICU). The Bundle Board was piloted for 6 weeks in June 2022 and followed by a comparison phase, where one MICU had Bundle Board access and another MICU at the same center did not. We retrospectively applied tile color coding logic to prior nursing documentation from 2021 until the pilot phase to facilitate comparison pre- and post-Bundle Board release. RESULTS After adjusting for time, other quality improvement efforts, and nursing shift, multiple linear regression demonstrated a statistically significant improvement in the completion of catheter care and documentation during the pilot phase (p < 0.0001) and comparison phase (p = 0.002). The median duration of documented problematic conditions was significantly reduced during the pilot phase (p < 0.0001) and in the MICU with the Bundle Board (comparison phase, p = 0.027). CONCLUSION We successfully developed a data visualization tool that changed ICU provider behavior, resulting in increased completion and documentation of maintenance care and reduced duration of problematic conditions for invasive catheters in MICU patients.
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Affiliation(s)
- Claire Leilani Davis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Margot Bjoring
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Jordyn Hursh
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Samuel Smith
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Cheri Blevins
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Kris Blackstone
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Evie Nicholson
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Tracey Hoke
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Jonathan Michel
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Imre Noth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Andrew Barros
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Kyle Enfield
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
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Bradley AS, Dalton A. Navigating ethical dilemmas in trauma, resuscitation, and critical care. Int Anesthesiol Clin 2023; 61:62-66. [PMID: 37551584 DOI: 10.1097/aia.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- A Steven Bradley
- Department of Anesthesiology and Critical Care, University of Chicago Medical Center, Chicago, IL
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17
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Shami E, Gholipour K, Naghibi D, Azami-Aghdash S. The roles and challenges of the primary health care systems in epidemic management: a scoping review. Prim Health Care Res Dev 2023; 24:e55. [PMID: 37705282 PMCID: PMC10539738 DOI: 10.1017/s1463423623000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/21/2023] [Accepted: 08/02/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND AND AIM During the early stage of pandemics, primary health care (PHC) is the first point of contact with the health system for people. This study aimed to find the leading roles and challenges of the PHC system in dealing with the outbreak of infectious diseases. METHODS The current scoping review was conducted in 2022 using the Arkesy and O'Malley framework. A bibliographic search was conducted in PubMed, Web of Science, and Scopus databases. Following a Google Scholar search, a manual search in some journals, reference checks for articles, and a review of organizational reports, websites, and other sources of information were also conducted. Data were analyzed using the content-analysis method. FINDINGS Finally, 65 documents (42 articles and 23 reports, books, and news) were included in the study. Initially, 626 codes were extracted, and 132 final codes were categorized into eight main themes and 44 sub-themes. The main themes for the roles of PHC included: service provision, education and knowledge, surveillance, access, coordination and communication, management and leadership, infrastructure change and rapid preparation, and patient and community management. Regarding the challenges faced by PHC in the epidemic of infectious diseases, 24 key challenges were identified and categorized into four major areas. CONCLUSIONS Based on the results of the present study, there is a need for further studies to formulate and theorize the specific roles of PHC in managing infectious disease epidemics. The results of this study can be utilized by researchers and officials to inform their efforts in addressing this purpose.
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Affiliation(s)
- Elham Shami
- Iranian Center of Excellence in Health Management, Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamal Gholipour
- Social Determinants of Health Research Center, Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Deniz Naghibi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saber Azami-Aghdash
- Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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18
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Heidinger BA, Downar A, Frolic A, Downar J, Isenberg SR. Physician and administrator experience of preparing to implement Ontario's intensive care unit Triage Emergency Standard of Care during the COVID-19 pandemic: a qualitative study. CMAJ Open 2023; 11:E838-E846. [PMID: 37726116 PMCID: PMC10516683 DOI: 10.9778/cmajo.20220168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND As the COVID-19 pandemic created a surge in demand for critical care resources, the province of Ontario, Canada, released the Adult Critical Care Clinical Emergency Standard of Care for Major Surge (Emergency Standard of Care [ESoC]), a triage framework to guide the allocation of critical care resources in the expectation that intensive care units would be overwhelmed. Our aim was to understand physicians' and administrators' experiences and perceptions of planning to implement the ESoC, and to identify ways to improve critical care triage processes for future pandemics. METHODS We conducted semistructured qualitative interviews with critical care, emergency and internal medicine physicians, and hospital administrators from various Ontario health regions who were involved in their hospital's or region's ESoC implementation planning. Interviews were conducted virtually between April and October 2021. We analyzed the data using thematic analysis. RESULTS We conducted interviews with 11 physicians and 10 hospital administrators representing 9 health regions. We identified 4 themes regarding participants' preparation to implement the ESoC: infrastructure to enable effective triage implementation; social, medical and political supports to enable effective triage implementation; moral dimensions of triage implementation; and communication of triage results. Participants outlined administrative and implementation-related improvements that could be provided at the provincial level, such as billing codes for ESoC. They also suggested improving ethical supports for the usability and quality of the ESoC (e.g., designating an ethicist in each region), and ways to improve the efficiency and usability of the tools for assessing short-term mortality risk (e.g., create information technology solutions such as a dashboard). INTERPRETATION The implementation of a jurisdiction-level triage framework poses moral challenges for a health care system, but it also requires dedicated infrastructure, as well as institutional supports. Lessons learned from Ontario's process to prepare for ESoC implementation, as well as participants' suggestions, can be used for planning for current and future pandemics.
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Affiliation(s)
- Brandon A Heidinger
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Ariane Downar
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Andrea Frolic
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - James Downar
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont.
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19
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González-Castro A, Cuenca-Fito E, Peñasco Y, Fernandez A, Huertas Marín C, Dierssen-Soto T, Ferrero-Franco R, Rodríguez-Borregán JC. [Analysis of characteristics of elderly patients admitted to an intensive care unit during six waves of the SARS-CoV-2 pandemic: Implications for medical care]. Rev Esp Geriatr Gerontol 2023; 58:101377. [PMID: 37451199 PMCID: PMC10281214 DOI: 10.1016/j.regg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To analyze the characteristics of seriously ill elderly patients during the six waves of the COVID-19 pandemic. METHOD Retrospective, observational and analytical study of patients over 70 years of age admitted to the ICU (March-2020 to March-2022). Patients were categorized into three groups based on age: 70-74 years; 75-79 years; and >80 years. A descriptive and comparative analysis of the sample was initially performed; and a 28-, 60- and 90-day survival analysis using the Kaplan-Meier method. Multivariate survival analysis was performed by fitting a Cox model. RESULTS Of 301 patients, the lowest number of admissions occurred during the first wave (20 (6%)), compared to the wave with the highest number of admissions: the sixth wave (76 (25%)). The survival curves at 28 days, 60 days and 90 days showed a higher probability of survival in the younger age groups (P<.01 and P=.01, respectively). Troponin at admission (per unit, ng/l) showed a significant association with 28- and 60-day mortality (HR: 1.00; 95% CI: 1.00-1.01; P<.05). Taking the 1st wave of the pandemic as a reference, admission in the 3rd wave behaved as a protective factor against mortality at 28 and 60 days of follow-up (HR: 0.18; 95% CI: 0.02-0.64; P<.05; HR: 0.13; 95% CI: 0.02-0.64; P<.05, respectively). CONCLUSIONS The time of admission and biomarkers, such as troponin, constitute prognostic markers independent of age in the elderly population.
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Affiliation(s)
- Alejandro González-Castro
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Elena Cuenca-Fito
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Yhivian Peñasco
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Alba Fernandez
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Carmen Huertas Marín
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Trinidad Dierssen-Soto
- Departamento de Estadística y Salud Publica, Facultad de Medicina, Universidad de Cantabria, Santander, Cantabria, España
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20
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Bibler TM, Zainab A. Withdrawing extra corporeal membrane oxygenation (ECMO) against a family's wishes: Three permissible scenarios. J Heart Lung Transplant 2023; 42:849-852. [PMID: 36972748 DOI: 10.1016/j.healun.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
The ethical permissibility of unilaterally withdrawing life-sustaining technologies has been a perennial topic in transplant and critical care medicine, often focusing on CPR and mechanical ventilation. The permissibility of unilateral withdrawal of extracorporeal membrane oxygenation (ECMO) has been discussed sparingly. When addressed, authors have appealed to professional authority rather than substantive ethical analysis. In this Perspective, we argue that there are at least three (3) scenarios wherein healthcare teams would be justified in unilaterally withdrawing ECMO, despite the objections of the patient's legal representative. The ethical considerations that provide the groundwork for these scenarios are, primarily: equity, integrity, and the moral equivalence between withholding and withdrawing medical technologies. First, we place equity in the context of crisis standards of medicine. After this, we discuss professional integrity as it relates to the innovative usage of medical technologies. Finally, we discuss the ethical consensus known at the "equivalence thesis." Each of these considerations include a scenario and justification for unilateral withdrawal. We also provide three (3) recommendations that aim at preventing these challenges at their outset. Our conclusions and recommendations are not meant to be blunt arguments that ECMO teams wield whenever disagreement about the propriety of continued ECMO support arises. Instead, the onus will be on individual ECMO programs to evaluate these arguments and decide if they represent sensible, correct, and implementable starting points for clinical practice guidelines or policies.
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Affiliation(s)
- Trevor M Bibler
- Center for Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.
| | - Asma Zainab
- Department of Cardiovascular Anesthesia, Weill Cornell Medical College, New York, New York; Intensivist Cardiovascular Surgical ICU, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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21
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A'la R, Wijaya AY, Susilowati H, Kuncorojakti S, Diyantoro, Rahmahani J, Rantam FA. Inactivated SARS-CoV-2 vaccine candidate immunization on non-human primate animal model: B-cell and T-cell responses immune evaluation. Heliyon 2023; 9:e18039. [PMID: 37519714 PMCID: PMC10372371 DOI: 10.1016/j.heliyon.2023.e18039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 08/01/2023] Open
Abstract
Background SARS-CoV-2 vaccine was proven to be an effective and efficient measure for mitigating pandemic. COVID-19 infection and mortality subsided along with the increaseing COVID-19 vaccination coverage. Vaccine and health resource equity are predominant factors in COVID-19 pandemic management. Vaccine development for Indonesia, aims to ensure a sustainable pandemic control and steady national stability restoration. A decent vaccine must induce immunity against COVID-19 with minimum adverse reaction. Immunogenicity and ability to induce neutralizing antibody evaluation needs to be performed as part of the SARS-CoV-2 inactivated vaccine development from East Java, Indonesia isolate (Vaksin Merah Putih-INAVAC). Objective This research demonstrated INAVAC performance in inducing the production neutralizing antibody along with its effects on CD4+ and CD8+ cells response in Macaca fascicularis (non-human primate). Methods Two dosages of 3 μg and 5 μg were tested, compared to sham (NaCl 0.9%) in 10 Macaca fascicularis (2 injection intramuscular with 14 days interval). All animals were monitored daily for clinical signs. Nasopharyngeal samples were analyzed using qRT-PCR while the serum were tested using ELISA and neutralization assay, whereas PBMCs were flowcytrometrically analyzed to measure CD4+ and CD8+ population. Results It is observed that both vaccine doses could stimulate relatively similar immune response and neutralizing antibody (end GMT post challenge = 905,1), whereas higher CD8+ cells response were reported in the 5 μg group after the 3rd day post-challenge. The dose of vaccine that produce adequate immune cell stimulation with neutralizing antibody induction can be adopted to clinical study, as favorable result of these parameters could predict minimum adverse reaction from inflammation response with balanced immune response. Conclusions Therefore, it is concluded that Vaksin Merah Putih-INAVAC with 3 μg dose showed a favorable potential to be developed and tested as human vaccine.
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Affiliation(s)
- Rofiqul A'la
- Faculty of Veterinary Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Helen Susilowati
- Research Center for Vaccine Technology and Development, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Suryo Kuncorojakti
- Department of Veterinary Anatomy, Faculty of Veterinary Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Diyantoro
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Indonesia
| | - Jola Rahmahani
- Virology and Immunology Laboratory, Department of Microbiology, Faculty of Veterinary Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Fedik Abdul Rantam
- Research Center for Vaccine Technology and Development, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
- Virology and Immunology Laboratory, Department of Microbiology, Faculty of Veterinary Medicine, Universitas Airlangga, Surabaya, Indonesia
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22
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Garber S, Brunner JO, Heller AR, Marckmann G, Bartenschlager CC. [Simulation of mortality after different ex-ante and ex-post-triage methods in people with disabilities and comorbidities]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01302-3. [PMID: 37358616 PMCID: PMC10400691 DOI: 10.1007/s00101-023-01302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/24/2023] [Accepted: 05/10/2023] [Indexed: 06/27/2023]
Abstract
The significant increase in patients during the COVID-19 pandemic presented the healthcare system with a variety of challenges. The intensive care unit is one of the areas particularly affected in this context. Only through extensive infection control measures as well as an enormous logistical effort was it possible to treat all patients requiring intensive care in Germany even during peak phases of the pandemic, and to prevent triage even in regions with high patient pressure and simultaneously low capacities. Regarding pandemic preparedness, the German Parliament passed a law on triage that explicitly prohibits ex post (tertiary) triage. In ex post triage, patients who are already being treated are included in the triage decision and treatment capacities are allocated according to the individual likelihood of success. Legal, ethical, and social considerations for triage in pandemics can be found in the literature, but there is no quantitative assessment with respect to different patient groups in the intensive care unit. This study addressed this gap and applied a simulation-based evaluation of ex ante (primary) and ex post triage policies in consideration of survival probabilities, impairments, and pre-existing conditions. The results show that application of ex post triage based on survival probabilities leads to a reduction in mortality in the intensive care unit for all patient groups. In the scenario close to a real-world situation, considering different impaired and prediseased patient groups, a reduction in mortality of approximately 15% was already achieved by applying ex post triage on the first day. This mortality-reducing effect of ex post triage is further enhanced as the number of patients requiring intensive care increases.
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Affiliation(s)
- Sara Garber
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
| | - Jens O Brunner
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
- Professor of Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Lyngby, Dänemark
| | - Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universitätsklinikum Augsburg, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Georg Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, Lessingstr. 2, 80336, München, Deutschland
| | - Christina C Bartenschlager
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
- Professur für Angewandte Datenwissenschaften im Gesundheitswesen, Nürnberg School of Health, Technische Hochschule Nürnberg Georg Simon Ohm, Klinikum Nürnberg, Nürnberg, Deutschland
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Butler CR, Wightman AG, Taylor JS, Hick JL, O’Hare AM. Experiences of US Clinicians Contending With Health Care Resource Scarcity During the COVID-19 Pandemic, December 2020 to December 2021. JAMA Netw Open 2023; 6:e2318810. [PMID: 37326986 PMCID: PMC10276299 DOI: 10.1001/jamanetworkopen.2023.18810] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance The second year of the COVID-19 pandemic saw periods of dire health care resource limitations in the US, sometimes prompting official declarations of crisis, but little is known about how these conditions were experienced by frontline clinicians. Objective To describe the experiences of US clinicians practicing under conditions of extreme resource limitation during the second year of the pandemic. Design, Setting, and Participants This qualitative inductive thematic analysis was based on interviews with physicians and nurses providing direct patient care at US health care institutions during the COVID-19 pandemic. Interviews were conducted between December 28, 2020, and December 9, 2021. Exposure Crisis conditions as reflected by official state declarations and/or media reports. Main Outcomes and Measures Clinicians' experiences as obtained through interviews. Results Interviews with 23 clinicians (21 physicians and 2 nurses) who were practicing in California, Idaho, Minnesota, or Texas were included. Of the 23 total participants, 21 responded to a background survey to assess participant demographics; among these individuals, the mean (SD) age was 49 (7.3) years, 12 (57.1%) were men, and 18 (85.7%) self-identified as White. Three themes emerged in qualitative analysis. The first theme describes isolation. Clinicians had a limited view on what was happening outside their immediate practice setting and perceived a disconnect between official messaging about crisis conditions and their own experience. In the absence of overarching system-level support, responsibility for making challenging decisions about how to adapt practices and allocate resources often fell to frontline clinicians. The second theme describes in-the-moment decision-making. Formal crisis declarations did little to guide how resources were allocated in clinical practice. Clinicians adapted practice by drawing on their clinical judgment but described feeling ill equipped to handle some of the operationally and ethically complex situations that fell to them. The third theme describes waning motivation. As the pandemic persisted, the strong sense of mission, duty, and purpose that had fueled extraordinary efforts earlier in the pandemic was eroded by unsatisfying clinical roles, misalignment between clinicians' own values and institutional goals, more distant relationships with patients, and moral distress. Conclusions and Relevance The findings of this qualitative study suggest that institutional plans to protect frontline clinicians from the responsibility for allocating scarce resources may be unworkable, especially in a state of chronic crisis. Efforts are needed to directly integrate frontline clinicians into institutional emergency responses and support them in ways that reflect the complex and dynamic realities of health care resource limitation.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Aaron G. Wightman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Janelle S. Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - John L. Hick
- Hennepin Healthcare, University of Minnesota, Minneapolis
| | - Ann M. O’Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Rahmatinejad Z, Hoseini B, Reihani H, Hanna AA, Pourmand A, Tabatabaei SM, Rahmatinejad F, Eslami S. Comparison of Six Scoring Systems for Predicting In-hospital Mortality among Patients with SARS-COV2 Presenting to the Emergency Department. Indian J Crit Care Med 2023; 27:416-425. [PMID: 37378368 PMCID: PMC10291668 DOI: 10.5005/jp-journals-10071-24463] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/19/2023] [Indexed: 06/29/2023] Open
Abstract
Background The study aimed to compare the prognostic accuracy of six different severity-of-illness scoring systems for predicting in-hospital mortality among patients with confirmed SARS-COV2 who presented to the emergency department (ED). The scoring systems assessed were worthing physiological score (WPS), early warning score (EWS), rapid acute physiology score (RAPS), rapid emergency medicine score (REMS), national early warning score (NEWS), and quick sequential organ failure assessment (qSOFA). Materials and methods A cohort study was conducted using data obtained from electronic medical records of 6,429 confirmed SARS-COV2 patients presenting to the ED. Logistic regression models were fitted on the original severity-of-illness scores to assess the models' performance using the Area Under the Curve for ROC (AUC-ROC) and Precision-Recall curves (AUC-PR), Brier Score (BS), and calibration plots were used to assess the models' performance. Bootstrap samples with multiple imputations were used for internal validation. Results The mean age of the patients was 64 years (IQR:50-76) and 57.5% were male. The WPS, REMS, and NEWS models had AUROC of 0.714, 0.705, and 0.701, respectively. The poorest performance was observed in the RAPS model, with an AUROC of 0.601. The BS for the NEWS, qSOFA, EWS, WPS, RAPS, and REMS was 0.18, 0.09, 0.03, 0.14, 0.15, and 0.11 respectively. Excellent calibration was obtained for the NEWS, while the other models had proper calibration. Conclusion The WPS, REMS, and NEWS have a fair discriminatory performance and may assist in risk stratification for SARS-COV2 patients presenting to the ED. Generally, underlying diseases and most vital signs are positively associated with mortality and were different between the survivors and non-survivors. How to cite this article Rahmatinejad Z, Hoseini B, Reihani H, Hanna AA, Pourmand A, Tabatabaei SM, et al. Comparison of Six Scoring Systems for Predicting In-hospital Mortality among Patients with SARS-COV2 Presenting to the Emergency Department. Indian J Crit Care Med 2023;27(6):416-425.
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Affiliation(s)
- Zahra Rahmatinejad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Benyamin Hoseini
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamidreza Reihani
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ameen Abu Hanna
- Department of Medical Informatics, Amsterdam UMC – Location AMC, University of Amsterdam, the Netherlands
| | - Ali Pourmand
- Department of Emergency Medicine, The George Washington University, School of Medicine and Health Sciences, Washington DC, United States
| | - Seyyed Mohammad Tabatabaei
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Rahmatinejad
- Department of Health Information Technology, Faculty of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeid Eslami
- Department of Medical Informatics, Faculty of Medicine; Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Medical Informatics, Amsterdam UMC – Location AMC, University of Amsterdam, the Netherlands
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25
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Heller AR, Bartenschlager C, Brunner JO, Marckmann G. [German "Triage Act"-Regulation with fatal consequences]. DIE ANAESTHESIOLOGIE 2023; 72:385-394. [PMID: 37233790 PMCID: PMC10215064 DOI: 10.1007/s00101-023-01286-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/27/2023]
Abstract
With the coming into force of § 5c of the Infection Protection Act (IfSG), the so-called Triage Act, on 14 December 2022, a protracted discussion has come to a provisional conclusion, the result of which physicians and social associations but also lawyers and ethicists are equally dissatisfied. The explicit exclusion of the discontinuation of treatment that has already begun in favor of new patients with better chances of success (so-called tertiary or ex-post triage) prevents allocation decisions with the aim of enabling as many patients as possible to beneficially participate in medical care under crisis conditions. The result of the new regulation is de facto a first come first served allocation, which is associated with the highest mortality even among individuals with limitations or disabilities and was rejected by a large margin as unfair in a population survey. Mandating allocation decisions based on the likelihood of success but which are not permitted to be consistently implemented and prohibiting, for example the use of age and frailty as prioritization criteria, although both factors most strongly determine the short-term probability of survival according to evident data, shows the contradictory and dogmatic nature of the regulation. The only remaining possibility is the consistent termination of treatment that is no longer indicated or desired by the patient, regardless of the current resource situation; however, if a different decision is made in a crisis situation than in a situation without a lack of resources, this practice would not be justified and would be punishable. Accordingly, the highest efforts must be set on legally compliant documentation, especially in the stage of decompensated crisis care in a region. The goal of enabling as many patients as possible to beneficially participate in medical care under crisis conditions is in any case thwarted by the new German Triage Act.
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Affiliation(s)
- A R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - C Bartenschlager
- Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Augsburg, Deutschland
| | - J O Brunner
- Zentrum für Interdisziplinäre Gesundheitsforschung, Universität Augsburg, Augsburg, Deutschland
| | - G Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
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26
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Dufner A. [Medical priority setting in pandemics and the ethics of discrimination]. Ethik Med 2023; 35:1-19. [PMID: 37360971 PMCID: PMC10139660 DOI: 10.1007/s00481-023-00765-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/08/2023] [Indexed: 06/28/2023]
Abstract
Definition of the problem As we have all learned in recent years, a pandemic can produce shortages in intensive care units. In our jurisdiction, this has led to a ruling by the federal constitutional court, according to which the lawmaker has to provide better protection for persons with disabilities in the event of medical priority setting. Arguments From an ethical perspective, this task requires a choice among various competing accounts on what exactly it is that makes a case of discrimination morally problematic. In addition, these accounts require amendments in order to encompass instances of indirect discrimination. Conclusion As this article demonstrates by appeal to a number of concrete triage criteria, a moderate account of discrimination does the best job of focusing attention on the core of the current issues. Among these issues are the extent to which perceptions of persons with specific pre-existing challenges generally have an impact on the structure of their social interactions.
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Affiliation(s)
- Annette Dufner
- Abt. Philosophie und FB Medical Humanities, Universität Bielefeld, Postfach 10 01 31, 33501 Bielefeld, Deutschland
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27
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Amaral N, Merkley J, Ronald K, Farquharson C, Ginty L, Heng D, Jeffs L. Focusing on fundamentals of care in an ICU setting during a pandemic. J Adv Nurs 2023; 79:970-979. [PMID: 35765250 DOI: 10.1111/jan.15333] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/29/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022]
Abstract
AIMS This manuscript aims to describe one acute care hospital's ICU journey during the COVID-19 pandemic and how fundamental care was central to the implementation of team-based models of care. BACKGROUND Over the course of the COVID-19 pandemic, team-based and alternative models of care are being employed to manage and address global shortages and surge capacity. Employing these alternate models of care required attention to ensure fundamental care needs of patients were being met. DESIGN/METHOD The following paper describes an ICU's journey of focusing on the delivery of the fundamentals of care through the implementation of team-based models of care to address the surge in patient care demands experienced in response to our global pandemic. CONCLUSIONS The implementation of an evidence-informed approach to optimizing models of care and staffing in the ICU amid the evolving COVID-19 waves in one acute-care hospital is provided. This local approach focused on meeting patients' fundamental care needs throughout the necessary introduction of team-based care models and staffing changes and drew from evolving evidence, the ILC Fundamentals of Care Framework, and regulatory guidance.
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Affiliation(s)
| | | | | | | | | | | | - Lianne Jeffs
- Bloomberg Faculty of Nursing, Sinai Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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28
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Akinosoglou K, Schinas G, Almyroudi MP, Gogos C, Dimopoulos G. The impact of age on intensive care. Ageing Res Rev 2023; 84:101832. [PMID: 36565961 PMCID: PMC9769029 DOI: 10.1016/j.arr.2022.101832] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
Caring for the elderly has always been challenging for the intensive care unit (ICU) physician. Concerns like frailty, comorbidities, polypharmacy and advanced directives come up even before admission into the unit. The COVID-19 pandemic has put forward a variety of issues concerning elderly populations, making the topic more relevant than ever. Admittance to the ICU, an unequivocally multifactorial decision, requires special consideration from the side of the physician when caring for an elderly person. Patients' wishes are to be respected and thus given priority. Triage assessment must also account for age-related physiological alterations and functional status. Once in the ICU, special attention should be given to age-related specificities, such as therapeutic interventions' controversial role, infection susceptibility, and post-operative care, that could potentially alter the course of hospitalization and affect outcomes. Following ICU discharge, ensuring proper rehabilitation for both survivors and their caregivers can improve long-term outcomes and subsequent quality of life. The pandemic and its implications may limit the standard of care for the elderly requiring ICU support. Socioeconomic factors that further perplex the situation must be addressed. Elderly patients currently represent a vast expanding population in ICU. Tailoring safe treatment plans to match patients' wishes, and personalized needs will guide critical care for the elderly from this time forward.
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Affiliation(s)
- Karolina Akinosoglou
- Department of Internal Medicine and Infectious Diseases, Medical School University of Patras, Greece.
| | - Georgios Schinas
- Department of Internal Medicine, Medical School University of Patras, Greece
| | - Maria Panagiota Almyroudi
- Department of Emergency Medicine, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, Greece
| | - Charalambos Gogos
- Department of Internal Medicine and Infectious Diseases, Medical School University of Patras, Greece
| | - George Dimopoulos
- 3rd Department of Critical Care, EVGENIDIO Hospital, National and Kapodistrian University of Athens, Medical School, Greece
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29
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Digby R, Manias E, Haines KJ, Orosz J, Ihle J, Bucknall TK. Staff experiences, perceptions of care, and communication in the intensive care unit during the COVID-19 pandemic in Australia. Aust Crit Care 2023; 36:66-76. [PMID: 36464524 PMCID: PMC9574938 DOI: 10.1016/j.aucc.2022.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/06/2022] [Accepted: 10/09/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission. AIM The aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale. METHODS This was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis. FINDINGS Four major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods. CONCLUSION The results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.
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Affiliation(s)
- Robin Digby
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety, Research, Institute for Health Transformation, Faculty of Health, Geelong, VIC 3220 Australia,Alfred Health, 55 Commercial Rd, Melbourne VIC 3004 Australia,Corresponding author
| | - Elizabeth Manias
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety, Research, Institute for Health Transformation, Faculty of Health, Geelong, VIC 3220 Australia
| | - Kimberley J. Haines
- Department of Physiotherapy, Western Health, Melbourne, Victoria,Department of Critical Care, School of Medicine, The University of Melbourne, Melbourne, Victoria
| | - Judit Orosz
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Joshua Ihle
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Tracey K. Bucknall
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety, Research, Institute for Health Transformation, Faculty of Health, Geelong, VIC 3220 Australia,Alfred Health, 55 Commercial Rd, Melbourne VIC 3004 Australia
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Donat N, Mellati N, Frumento T, Cirodde A, Gette S, Guitard PG, Hoffmann C, Veber B, Leclerc T. Validation of a pre-established triage protocol for critically ill patients in a COVID-19 outbreak under resource scarcity: A retrospective multicenter cohort study. PLoS One 2023; 18:e0285690. [PMID: 37167306 PMCID: PMC10174588 DOI: 10.1371/journal.pone.0285690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/28/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION In case of COVID-19 related scarcity of critical care resources, an early French triage algorithm categorized critically ill patients by probability of survival based on medical history and severity, with four priority levels for initiation or continuation of critical care: P1 -high priority, P2 -intermediate priority, P3 -not needed, P4 -not appropriate. This retrospective multi-center study aimed to assess its classification performance and its ability to help saving lives under capacity saturation. METHODS ICU patients admitted for severe COVID-19 without triage in spring 2020 were retrospectively included from three hospitals. Demographic data, medical history and severity items were collected. Priority levels were retrospectively allocated at ICU admission and on ICU day 7-10. Mortality rate, cumulative incidence of death and of alive ICU discharge, length of ICU stay and of mechanical ventilation were compared between priority levels. Calculated mortality and survival were compared between full simulated triage and no triage. RESULTS 225 patients were included, aged 63.1±11.9 years. Median SAPS2 was 40 (IQR 29-49). At the end of follow-up, 61 (27%) had died, 26 were still in ICU, and 138 had been discharged. Following retrospective initial priority allocation, mortality rate was 53% among P4 patients (95CI 34-72%) versus 23% among all P1 to P3 patients (95CI 17-30%, chi-squared p = 5.2e-4). The cumulative incidence of death consistently increased in the order P3, P1, P2 and P4 both at admission (Gray's test p = 3.1e-5) and at reassessment (p = 8e-5), and conversely for that of alive ICU discharge. Reassessment strengthened consistency. Simulation under saturation showed that this two-step triage protocol could have saved 28 to 40 more lives than no triage. CONCLUSION Although it cannot eliminate potentially avoidable deaths, this triage protocol proved able to adequately prioritize critical care for patients with highest probability of survival, hence to save more lives if applied.
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Affiliation(s)
- Nicolas Donat
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
| | - Nouchan Mellati
- ICU, Mercy Regional Hospital, Metz, France
- Legouest Military Teaching Hospital, Metz, France
| | | | - Audrey Cirodde
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
| | | | | | - Clément Hoffmann
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
| | - Benoît Veber
- ICU, Rouen University Hospital, Rouen, France
- Faculty of Medicine, Rouen University, Rouen, France
| | - Thomas Leclerc
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
- Val-de-Grâce Military Medical Academy, Paris, France
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Impact of noninvasive ventilation at a municipal emergency department on ICU admissions. Wien Klin Wochenschr 2023; 135:28-34. [PMID: 36441338 PMCID: PMC9703406 DOI: 10.1007/s00508-022-02111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 10/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 2015, the emergency department of a municipal hospital in Vienna began to perform noninvasive ventilation (NIV) on patients admitted for acute respiratory failure, given no intubation criteria were met. The intention of this study was to show to which type of hospital unit patients were transferred after undergoing NIV in the emergency department. Additionally, the impact of the underlying disease, a patient's sex and age and the year of intervention were analyzed. METHODS A single-center retrospective exploratory study was performed on 371 patients. All patients with acute respiratory failure who were noninvasively ventilated at the study center emergency department from 2015 to 2018 were eligible. Relevant data were extracted from the patient's medical records. RESULTS A total of 43.7% (95% confidence interval, CI 38.8-48.5%) of patients were successfully stabilized in the emergency department through NIV and subsequently transferred to a normal care unit or discharged. This nonintensive care admission rate was significantly associated with certain underlying medical conditions, age and year of intervention. A further 19.7% (95% CI 15.6-23.7%) of patients were transferred to an intermediate care unit instead of an intensive care unit. CONCLUSION These findings emphasize the importance of noninvasive ventilation at the emergency department in reducing load on intensive care units and ensuring an efficient hospital workflow. Nonintensive care admission rate appears to be the highest in patients with pulmonary edema, especially in the higher age range and is also associated with the level of staff training. Prospective trials are needed to accurately confirm these correlations.
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Ramirez CC, Farmer Y, Bouthillier ME. Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review. DISCOVER HEALTH SYSTEMS 2023; 2:16. [PMID: 37206881 PMCID: PMC10169297 DOI: 10.1007/s44250-023-00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/14/2023] [Indexed: 05/21/2023]
Abstract
Background To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers. Objectives To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic. Methods The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies. Results Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19. Conclusions There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers. Supplementary Information The online version contains supplementary material available at 10.1007/s44250-023-00027-9.
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Affiliation(s)
- Claudia Calderon Ramirez
- Biomedical Sciences Program, Clinical Ethics, Faculty of Medicine, Université de Montréal, 2900 Bd Édouard-Montpetit, Montréal, Québec H3T 1J4 Canada
| | - Yanick Farmer
- Department of Social and Public Communication, Faculty of Communication, Université du Québec à Montréal, C.P 8888, Succursale Centre-Ville, Montréal, Québec H3C 3P8 Canada
| | - Marie-Eve Bouthillier
- Department of Family and Emergency Medicine and Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, 2900 Bd Édouard-Montpetit, Montréal, Québec H3T 1J4 Canada
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The impact of a "short-term" basic intensive care training program on the knowledge of nonintensivist doctors during the COVID-19 pandemic: An experience from a population-dense low- and middle-income country. Aust Crit Care 2023; 36:138-144. [PMID: 36123237 PMCID: PMC9404177 DOI: 10.1016/j.aucc.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 08/07/2022] [Accepted: 08/13/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The utility of basic intensive care unit (ICU) training comprising a "1-day course" has been scientifically evaluated and reported in very few studies, with almost no such study from resource-limited settings. AIM The study assessed the utility of basic ICU training comprising of a "1-day course" in increasing the knowledge of nonintensivist doctors. MATERIALS AND METHODS This is an observational study conducted at a medical university in North India in 2020. The participants were nonintensivist doctors attending the course. The course was designed by intensivists, and it had four domains. The participants were categorised on the basis of their duration of ICU experience and broad speciality. Pretest and posttest was administered, which was analysed to ascertain the gain in the knowledge score. RESULTS A total of 252 participants were included, of which the majority were from the clinical medicine speciality (85.3%) and had ICU experience of 1-6 months (47.6%). There was a significant improvement in the mean total score of the participants after training from 14/25 to 19/25, with a mean difference (MD) of 5.02 (p < 0.001). Based on ICU experience, in groups I (<1 month), II (1-6 months), and III (>6 months), there was a significant improvement in the total score of the participants after training with MD with 95% confidence interval (CI) limits of 5.27 (4.65-5.90), 4.70 (4.38-5.02), and 5.33 (4.89-5.78), respectively. In the clinical surgery specialty (n = 37), there was a significant improvement in the total score after training from 11/25 to 16.4/25 with an MD (95% CI limits) of 5.38 (4.4-6.3). Similarly, in the clinical medicine group (n = 215), the MD (95% CI limits) score after training was 4.95 (4.71-5.20), from 14.5/25 to 19.5/25. In feedback, more than half of the participants showed interest in joining ICU after training. CONCLUSIONS Training nonintensivist doctors for 1 day can be useful in improving their knowledge, regardless of their prior ICU experience and speciality.
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Relationship Between a State-Directed Lockdown on Non-COVID-19-related ICU Admissions and Mortality in a Multicenter Colorado Healthcare System. Crit Care Explor 2022; 4:e0791. [PMID: 36506833 PMCID: PMC9726320 DOI: 10.1097/cce.0000000000000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Colorado issued a month long statewide lockdown on March 26, 2020, during the initial surge of the COVID-19 pandemic. The impact of this mandate on non-COVID-19 ICU admission rates and outcomes is unclear. DESIGN We performed a retrospective analysis of all medical ICU admissions in the University of Colorado Health System in four predefined periods: 1) prepandemic (2 mo prior to lockdown period 1); 2) mandated lockdown from March 26 to April 26, 2020 (period 2); 3) between surges (period 3); and 4) nonmandated lockdown surge (between November 1, 2020, and March 31, 2021, period 4). SETTING Nonsurgical ICU admissions at the University of Colorado Health Systems, including 10 hospitals throughout Colorado. SUBJECTS All ICU admissions in four predefined time periods. MEASUREMENTS AND MAIN RESULTS We included 13,787 patients who were admitted during the four study periods. The 28-day mortality rates for non-COVID-19 ICU admissions following index ICU admission were 13.6%, 18.0%, 13.5%, and 16.0% across periods 1-4, respectively. However, the increased odds in non-COVID-19 ICU mortality during the mandated lockdown period relative to prepandemic 1 (odds ratio [OR], 1.39; 95% CI, 1.11-1.72; p = 0.0.04) was attenuated and nonsignificant after adjustment for demographics, comorbidities, diagnosis flags, and severity (OR, 1.15; 95% CI, 0.89-1.48; p = 0.27). Similar results were found in time-to-event analyses. The most common diagnosis in each time period was acute respiratory failure (ARF), and we found it to have increased during lockdown (p < 0.001), whereas sepsis admissions increased during and decreased after lockdown (p = 0.004). Admissions for alcohol withdrawal syndrome (AWS) increased during lockdown and 6 months afterwards (p = 0.005). CONCLUSIONS For non-COVID-19-related ICU admissions, mortality rate was similar before, during, and after Colorado's month long lockdown after confounder adjustment, including typical ICU admission flags. Primary admission diagnoses shifted throughout the predefined study periods with more admissions for severe critical diagnoses (i.e., ARF, sepsis, AWS) occurring during the mandated lockdown and nonmandated lockdown periods compared with the prepandemic and between surge period. This would suggest that the perceived increase in mortality during the lockdown for non-COVID-19 ICU admissions may be related to a shift inpatient demographics.
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Hollenberg SM, Janz DR, Hua M, Malesker M, Qadir N, Rochwerg B, Sessler CN, Tatem G, Rice TW. COVID-19: Lessons Learned, Lessons Unlearned, Lessons for the Future. Chest 2022; 162:1297-1305. [PMID: 35952767 PMCID: PMC9512535 DOI: 10.1016/j.chest.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 07/10/2022] [Accepted: 08/02/2022] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 pandemic has affected clinicians in many different ways. Clinicians have their own experiences and lessons that they have learned from their work in the pandemic. This article outlines a few lessons learned from the eyes of CHEST Critical Care Editorial Board members, namely practices which will be abandoned, novel practices to be adopted moving forward, and proposed changes to the health care system in general. In an attempt to start the discussion of how health care can grow from the pandemic, the editorial board members outline their thoughts on these lessons learned.
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Affiliation(s)
- Steven M Hollenberg
- Emory Heart & Vascular Institute, Emory University School of Medicine, Atlanta, GA
| | - David R Janz
- Medical Critical Care Services, University Medical Center New Orleans, Louisiana State University School of Medicine New Orleans, New Orleans, LA
| | - May Hua
- Mailman School of Public Health, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Mark Malesker
- Department of Pharmacy Practice, School of Pharmacy and Health Professions, Creighton University, Omaha, NE
| | - Nida Qadir
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | | | - Curtis N Sessler
- Center for Adult Critical Care, Virginia Commonwealth University Health System, Richmond, VA
| | - Geneva Tatem
- Pulmonary and Critical Care Medicine Fellowship Program, Henry Ford Health, Detroit, MI
| | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN.
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Meier LJ. Systemising triage: COVID-19 guidelines and their underlying theories of distributive justice. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:703-714. [PMID: 35796935 PMCID: PMC9261143 DOI: 10.1007/s11019-022-10101-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 06/14/2023]
Abstract
The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. Since most of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice-which is crucial for both managing the current pandemic and in preparation for the next global health crisis.
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Affiliation(s)
- Lukas J Meier
- Churchill College, University of Cambridge, Storey's Way, Cambridge, CB3 0DS, UK.
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Knochel K, Adaktylos-Surber K, Schmolke EM, Meier LJ, Kuehlmeyer K, Ulm K, Buyx A, Schneider G, Heim M. Preparing for the Worst-Case Scenario in a Pandemic: Intensivists Simulate Prioritization and Triage of Scarce ICU Resources. Crit Care Med 2022; 50:1714-1724. [PMID: 36222541 PMCID: PMC9668365 DOI: 10.1097/ccm.0000000000005684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Simulation and evaluation of a prioritization protocol at a German university hospital using a convergent parallel mixed methods design. DESIGN Prospective single-center cohort study with a quantitative analysis of ICU patients and qualitative content analysis of two focus groups with intensivists. SETTING Five ICUs of internal medicine and anesthesiology at a German university hospital. PATIENTS Adult critically ill ICU patients ( n = 53). INTERVENTIONS After training the attending senior ICU physicians ( n = 13) in rationing, an impending ICU congestion was simulated. All ICU patients were rated according to their likelihood to survive their acute illness (good-moderate-unfavorable). From each ICU, the two patients with the most unfavorable prognosis ( n = 10) were evaluated by five prioritization teams for triage. MEASUREMENTS AND MAIN RESULTS Patients nominated for prioritization visit ( n = 10) had higher Sequential Organ Failure Assessment scores and already a longer stay at the hospital and on the ICU compared with the other patients. The order within this worst prognosis group was not congruent between the five teams. However, an in-hospital mortality of 80% confirmed the reasonable match with the lowest predicted probability of survival. Qualitative data highlighted the tremendous burden of triage and the need for a team-based consensus-oriented decision-making approach to ensure best possible care and to support professionals. Transparent communication within the teams, the hospital, and to the public was seen as essential for prioritization implementation. CONCLUSIONS To mitigate potential bias and to reduce the emotional burden of triage, a consensus-oriented, interdisciplinary, and collaborative approach should be implemented. Prognostic comparative assessment by intensivists is feasible. The combination of long-term ICU stay and consistently high Sequential Organ Failure Assessment scores resulted in a greater risk for triage in patients. It remains challenging to reliably differentiate between patients with very low chances to survive and requires further conceptual and empirical research.
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Affiliation(s)
- Kathrin Knochel
- Clinical Ethics, Institute of History and Ethics in Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Katharina Adaktylos-Surber
- Clinical Ethics, Institute of History and Ethics in Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Eva-Maria Schmolke
- Clinical Ethics, Institute of History and Ethics in Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Lukas J Meier
- Clinical Ethics, Institute of History and Ethics in Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Katja Kuehlmeyer
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany
| | - Kurt Ulm
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, School of Medicine, Munich, Germany
| | - Alena Buyx
- Clinical Ethics, Institute of History and Ethics in Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Markus Heim
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
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Martín-Rodríguez F, Sanz-García A, Ortega GJ, Delgado-Benito JF, García Villena E, Mazas Pérez-Oleaga C, López-Izquierdo R, Castro Villamor MA. One-on-one comparison between qCSI and NEWS scores for mortality risk assessment in patients with COVID-19. Ann Med 2022; 54:646-654. [PMID: 35193439 PMCID: PMC8881067 DOI: 10.1080/07853890.2022.2042590] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To compare the predictive value of the quick COVID-19 Severity Index (qCSI) and the National Early Warning Score (NEWS) for 90-day mortality amongst COVID-19 patients. METHODS Multicenter retrospective cohort study conducted in adult patients transferred by ambulance to an emergency department (ED) with suspected COVID-19 infection subsequently confirmed by a SARS-CoV-2 test (polymerase chain reaction). We collected epidemiological data, clinical covariates (respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature, level of consciousness and use of supplemental oxygen) and hospital variables. The primary outcome was cumulative all-cause mortality during a 90-day follow-up, with mortality assessment monitoring time points at 1, 2, 7, 14, 30 and 90 days from ED attendance. Comparison of performances for 90-day mortality between both scores was carried out by univariate analysis. RESULTS From March to November 2020, we included 2,961 SARS-CoV-2 positive patients (median age 79 years, IQR 66-88), with 49.2% females. The qCSI score provided an AUC ranging from 0.769 (1-day mortality) to 0.749 (90-day mortality), whereas AUCs for NEWS ranging from 0.825 for 1-day mortality to 0.777 for 90-day mortality. At all-time points studied, differences between both scores were statistically significant (p < .001). CONCLUSION Patients with SARS-CoV-2 can rapidly develop bilateral pneumonias with multiorgan disease; in these cases, in which an evacuation by the EMS is required, reliable scores for an early identification of patients with risk of clinical deterioration are critical. The NEWS score provides not only better prognostic results than those offered by qCSI at all the analyzed time points, but it is also better suited for COVID-19 patients.KEY MESSAGESThis work aims to determine whether NEWS is the best score for mortality risk assessment in patients with COVID-19.AUCs for NEWS ranged from 0.825 for 1-day mortality to 0.777 for 90-day mortality and were significantly higher than those for qCSI in these same outcomes.NEWS provides a better prognostic capacity than the qCSI score and allows for long-term (90 days) mortality risk assessment of COVID-19 patients.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Unidad Móvil de Emergencias Valladolid I, Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain.,Centro de Simulación Clínica Avanzada, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de Investigación Sanitaria del Hospital de la Princesa (IIS-IP), Madrid, Spain
| | - Guillermo J Ortega
- Data Analysis Unit, Instituto de Investigación Sanitaria del Hospital de la Princesa (IIS-IP), Madrid, Spain.,Consejo Nacional de Investigaciones Científicas y Técnicas, CONICET, Buenos Aires, Argentina
| | - Juan F Delgado-Benito
- Unidad Móvil de Emergencias de Salamanca, Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Eduardo García Villena
- Escuela Politécnica Superior, Universidad Europea del Atlántico, Santander, Spain.,Departamento de Medio Ambiente y Sostenibilidad, Universidad Internacional Iberoamericana, Arecibo, Puerto Rico (EE.UU)
| | | | - Raúl López-Izquierdo
- Servicio de Urgencias, Hospital Universitario Rio Hortega de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Miguel A Castro Villamor
- Centro de Simulación Clínica Avanzada, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
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Abstract
Pandemics, increases in disease incidence that affect multiple regions of the world, present huge challenges to health care systems and in particular to policymakers, public health authorities, clinicians, and all health care workers (HCWs). The recent COVID-19 pandemic has resulted in millions of severely ill patients, many of whom who have required hospital and intensive care unit (ICU) admission. The discipline of critical care is a vital and integral component of pandemic preparedness. Safe and effective critical care has the potential to improve outcomes, motivate individuals to seek timely medical attention, and attenuate the devastating sequelae of a severe pandemic. To achieve this, suitable critical care planning and preparation are essential.
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Nath A, Sudarshan KL, Rajput GK, Mathew S, Chandrika KRR, Mathur P. A rapid assessment of the impact of coronavirus disease (COVID- 19) pandemic on health care & service delivery for noncommunicable diseases in India. Diabetes Metab Syndr 2022; 16:102607. [PMID: 36115089 PMCID: PMC9451930 DOI: 10.1016/j.dsx.2022.102607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/17/2022] [Accepted: 08/21/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND AIM The coronavirus disease (COVID-19) pandemic had disrupted the availability, access and utilisation of routine health care services. The present study aimed to assess the impact of COVID-19 pandemic restrictions on India's Non communicable Disease (NCD) health care service delivery. METHODS The study included existing hospitals in disease registry network of the Indian Council of Medical Research-National Centre for Disease Informatics and Research (ICMR-NCDIR), Bengaluru. The study participants comprised site investigators who were clinicians from many specialities, including general medicine, surgery, cancer, neurology, cardiology, and endocrinology. A standardised questionnaire was prepared to collect data on NCD health care services at the respective hospitals over three months from March to May 2020. RESULTS Out of 153 hospitals approached for the study, 106 (70%) agreed to participate. Of these, 16 hospitals fully converted for COVID-19 care were excluded from the study. Thus, data from 90 hospitals were included in the final analysis. There had been a total disruption of NCD-related healthcare services during the three months in 44% of the hospitals. In April 2020, the outpatient attendance for over one-third of the hospitals was reduced by more than 75%. Admissions for planned surgeries for cancer treatment were reduced by more than 75% for about 40% of the hospitals. Preventive activities and population-based screening for diabetes, hypertension and cancer appear to have been adversely affected, with about one-third of the hospitals reporting total disruption in April and May 2020. As many as 60% of the institutions reported adequate availability of doctors. Over 91% of the institutions had preparedness/action plans to ensure the continuity of NCD services. CONCLUSION The study shows that despite adequate human and material resources, NCD outpatient services, elective surgeries and population-based screening were severely affected. Most institutions were prepared to overcome the pandemic-imposed disruption and ensure a continuum of care for NCDs'.
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Affiliation(s)
- Anita Nath
- ICMR-National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, India.
| | | | - Gurpreet Kaur Rajput
- ICMR-National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, India.
| | - Stany Mathew
- ICMR-National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, India.
| | | | - Prashant Mathur
- ICMR-National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, India.
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Tang F, Hammel IS, Andrew MK, Ruiz JG. COVID-19 mRNA vaccine effectiveness against hospitalisation and death in veterans according to frailty status during the SARS-CoV-2 delta (B.1.617.2) variant surge in the USA: a retrospective cohort study. THE LANCET. HEALTHY LONGEVITY 2022; 3:e589-e598. [PMID: 35935474 PMCID: PMC9342932 DOI: 10.1016/s2666-7568(22)00166-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Studies have shown that COVID-19 vaccination is effective at preventing infection and death in older populations. However, whether vaccination effectiveness is reduced in patients with frailty is unclear. We aimed to compare vaccine effectiveness against hospitalisation and death after COVID-19 during the surge of the delta (B.1.617.2) variant of SARS-CoV-2 according to patients' frailty status. Methods In this retrospective cohort study, we used data derived from the US Veterans Health Administration (VHA) facilities and the US Department of Veterans Affairs (VA) COVID-19 Shared Data Resource, which contains information from the VA National Surveillance Tool, death certificates, and National Cemetery Administration. We included veterans aged 19 years or older who tested positive for SARS-CoV-2 using RT-PCR or antigen tests between July 25 and Sept 30, 2021, with no record of a previous positive test. Deaths were identified through VHA facilities, death certificates, and National Cemetery Administration data available from VA databases. We also retrieved data including sociodemographic characteristics, medical conditions diagnosed at baseline, frailty score, and vaccination information. The primary outcomes were COVID-19-associated hospitalisations and all-cause deaths at 30 days from testing positive for SARS-CoV-2. The odds ratio (OR) for COVID-19-associated hospitalisation and hazard ratio (HR) for death of vaccinated patients compared with the unvaccinated patients were estimated according to frailty categories of robust, pre-frail, or frail. Vaccine effectiveness was estimated as 1 minus the OR for COVID-19-associated hospitalisation, and 1 minus the HR for death. Findings We identified 57 784 veterans (mean age 57·5 years [SD 16·7], 50 642 [87·6%] males, and 40 743 [70·5%] White people), of whom 28 497 (49·3%) were categorised as robust, 16 737 (29·0%) as pre-frail, and 12 550 (21·7%) as frail. There were 2577 all-cause deaths (676 [26·2%] in the vaccinated group and 1901 [73·8%] in the unvaccinated group), and 7857 COVID-19-associated hospitalisations (2749 [35·0%] in the vaccinated group and 5108 [65·0%] in the unvaccinated group) within 30 days of a positive SARS-CoV-2 test. Vaccine effectiveness against COVID-19-associated hospitalisation within 30 days of a positive SARS-CoV-2 test was 65% (95% CI 61-69) in the robust group, 54% (48-58) in the pre-frail group, and 36% (30-42) in the frail group. By 30 days of a positive SARS-CoV-2 test, the vaccine effectiveness for all-cause death was 79% (95% CI 74-84) in the robust group, 79% (75-83) in the pre-frail group, and 68% (63-71) in the frail group. Interpretation Compared with non-frail patients (pre-frail and robust), those with frailty had lower levels of vaccination protection against COVID-19-associated hospitalisation and all-cause death. Future studies investigating COVID-19 vaccine effectiveness should incorporate frailty assessments and actively recruit older adults with frailty. Funding Miami VA Healthcare System Geriatric Research Education and Clinical Center.
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Affiliation(s)
- Fei Tang
- Geriatric Research Education and Clinical Center, Miami VA Healthcare System, Miami, FL, USA
| | - Iriana S Hammel
- Geriatric Research Education and Clinical Center, Miami VA Healthcare System, Miami, FL, USA
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Melissa K Andrew
- Department of Medicine (Geriatrics) and Canadian Center for Vaccinology, Dalhousie University, Halifax, NS, Canada
| | - Jorge G Ruiz
- Geriatric Research Education and Clinical Center, Miami VA Healthcare System, Miami, FL, USA
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Gasa M, Ruiz-Albert Y, Cordoba-Izquierdo A, Sarasate M, Cuevas E, Suarez-Cuartin G, Méndez L, Alfaro-Álvarez JC, Sabater-Riera J, Pérez-Fernández XL, Molina-Molina M, Santos S. Outcomes of COVID-19 Patients Admitted to the Intermediate Respiratory Care Unit: Non-Invasive Respiratory Therapy in a Sequential Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10772. [PMID: 36078488 PMCID: PMC9518070 DOI: 10.3390/ijerph191710772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 06/15/2023]
Abstract
The intermediate respiratory care units (IRCUs) have a pivotal role managing escalation and de-escalation between the general wards and the intensive care units (ICUs). Since the COVID-19 pandemic began, the early detection of patients that could improve on non-invasive respiratory therapies (NRTs) in IRCUs without invasive approaches is crucial to ensure proper medical management and optimize limiting ICU resources. The aim of this study was to assess factors associated with survival, ICU admission and intubation likelihood in COVID-19 patients admitted to IRCUs. Observational retrospective study in consecutive patients admitted to the IRCU of a tertiary hospital from March 2020 to April 2021. Inclusion criteria: hypoxemic respiratory failure (SpO2 ≤ 94% and/or respiratory rate ≥ 25 rpm with FiO2 > 50% supplementary oxygen) due to acute COVID-19 infection. Demographic, comorbidities, clinical and analytical data, and medical and NRT data were collected at IRCU admission. Multivariate logistic regression models assessed factors associated with survival, ICU admission, and intubation. From 679 patients, 79 patients (12%) had an order to not do intubation. From the remaining 600 (88%), 81% survived, 41% needed ICU admission and 37% required intubation. In the IRCU, 51% required non-invasive ventilation (NIV group) and 49% did not (non-NIV group). Older age and lack of corticosteroid treatment were associated with higher mortality and intubation risk in the scheme, which could be more beneficial in severe forms. Initial NIV does not always mean worse outcomes.
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Affiliation(s)
- Mercè Gasa
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
- Department of Medicine, Campus Bellvitge, Universitat de Barcelona, 08907 L’Hospitalet de Llobregat, Spain
| | - Yolanda Ruiz-Albert
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Ana Cordoba-Izquierdo
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Mikel Sarasate
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Ester Cuevas
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Guillermo Suarez-Cuartin
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Lidia Méndez
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | | | - Joan Sabater-Riera
- Critical Care Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (J.S.-R.); (X.L.P.-F.)
| | - Xosé L. Pérez-Fernández
- Critical Care Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (J.S.-R.); (X.L.P.-F.)
| | - María Molina-Molina
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
- Department of Medicine, Campus Bellvitge, Universitat de Barcelona, 08907 L’Hospitalet de Llobregat, Spain
| | - Salud Santos
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
- Department of Medicine, Campus Bellvitge, Universitat de Barcelona, 08907 L’Hospitalet de Llobregat, Spain
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Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill. J Clin Med 2022; 11:jcm11164705. [PMID: 36012944 PMCID: PMC9410153 DOI: 10.3390/jcm11164705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/31/2022] [Accepted: 08/08/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06−1.19), 1.17 (1.1−1.24), and 1.21 (1.14−1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75−0.97] vs. 0.88 [0.76−0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71−0.93) and 0.87 (0.77−0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.
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Ioannides KLH, Dekker AM, Shin ME, Schriger DL. Ambulances Required to Relieve Overcapacity Hospitals: A Novel Measure of Hospital Strain During the COVID-19 Pandemic in the United States. Ann Emerg Med 2022; 80:301-313.e3. [PMID: 35940995 PMCID: PMC9356618 DOI: 10.1016/j.annemergmed.2022.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/10/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022]
Abstract
Study objective Methods Results Conclusion
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Affiliation(s)
- Kimon L H Ioannides
- Department of Emergency Medicine, University of California, San Francisco-Fresno Medical Education Program, Fresno, CA; Department of Emergency Medicine, University of California, Los Angeles, CA.
| | - Annette M Dekker
- Department of Emergency Medicine, University of California, Los Angeles, CA
| | - Michael E Shin
- Department of Geography, University of California, Los Angeles, CA
| | - David L Schriger
- Department of Emergency Medicine, University of California, Los Angeles, CA
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45
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Fjølner J, Haaland ØA, Jung C, de Lange DW, Szczeklik W, Leaver S, Guidet B, Sviri S, Van Heerden PV, Beil M, Hartog CS, Flaatten H. Who gets the ventilator? A multicentre survey of intensivists' opinions of triage during the first wave of the COVID-19 pandemic. Acta Anaesthesiol Scand 2022; 66:859-868. [PMID: 35678326 PMCID: PMC9348162 DOI: 10.1111/aas.14094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/28/2022] [Accepted: 04/20/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic has caused a shortage of intensive care resources. Intensivists' opinion of triage and ventilator allocation during the COVID-19 pandemic is not well described. METHODS This was a survey concerning patient numbers, bed capacity, triage guidelines, and three virtual cases involving ventilator allocations. Physicians from 400 ICUs in a research network were invited to participate. Preferences were assessed with a five-point Likert scale. Additionally, age, gender, work experience, geography, and religion were recorded. RESULTS Of 437 responders 31% were female. The mean age was 44.4 (SD 11.1) with a mean ICU experience of 13.7 (SD 10.5) years. Respondents were mostly European (88%). Sixty-six percent had triage guidelines available. Younger patients and caretakers of children were favoured for ventilator allocation although this was less clear if this involved withdrawal of the ventilator from another patient. Decisions did not differ with ICU experience, gender, religion, or guideline availability. Consultation of colleagues or an ethical committee decreased with age and male gender. CONCLUSION Intensivists appeared to prioritise younger patients for ventilator allocation. The tendency to consult colleagues about triage decreased with age and male gender. Many found such tasks to be not purely medical and that authorities should assume responsibility for triage during resource scarcity.
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Affiliation(s)
- Jesper Fjølner
- Department of Anaesthesia and Intensive CareViborg Regional HospitalViborgDenmark
- Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Øystein Ariandsen Haaland
- Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
| | - Christian Jung
- Heinrich‐Heine‐University Duesseldorf, Medical Faculty, Department of CardiologyPulmonology and Vascular MedicineDuesseldorfGermany
| | - Dylan W. de Lange
- Department of Intensive Care MedicineUniversity Medical Center, University UtrechtUtrechtNetherlands
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative MedicineJagiellonian University Medical CollegeKrakowPoland
| | - Susannah Leaver
- General Intensive careSt George's University Hospital NHS Foundation trustLondonUK
| | - Bertrand Guidet
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé PubliqueEquipe: épidémiologie hospitalière qualité et organisation des soinsParisFrance
- Assistance Publique – Hôpitaux de ParisHôpital Saint‐Antoine, service de réanimation médicaleParisFrance
| | - Sigal Sviri
- Department of Medical Intensive CareHadassah University Medical CenterJerusalemIsrael
| | - Peter Vernon Van Heerden
- General Intensive Care Unit, Hadassah Medical Center and Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Michael Beil
- Department of Medical Intensive CareHadassah University Medical CenterJerusalemIsrael
| | - Christiane S. Hartog
- Department of Anesthesiology and Intensive Care MedicineCharité Universitätsmedizin BerlinBerlinGermany
- Klinik BavariaKreischaGermany
| | - Hans Flaatten
- Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of Anaesthesia and Intensive CareHaukeland University HospitalBergenNorway
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Sikder A, Dickhoner J, Kysh L, Musheghyan L, Shekerdimian S, Levine B, Espinoza J. International Collaboration to Develop a Remote Monitoring Web Application for COVID-19 Patients in Armenia Using an Agile Methodology (Preprint). JMIR Hum Factors 2022; 9:e40110. [DOI: 10.2196/40110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2022] Open
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Phattharapornjaroen P, Carlström E, Sivarak O, Tansuwannarat P, Chalermdamrichai P, Sittichanbuncha Y, Kongtoranin L, Phattranonuthai R, Marlow P, Winyuchonjaroen W, Pongpasupa N, Khorram-Manesh A. Community-Based Response to the COVID-19 Pandemic: Case Study of a Home Isolation centre using Flexible Surge Capacity. Public Health 2022; 211:29-36. [PMID: 35994836 PMCID: PMC9276643 DOI: 10.1016/j.puhe.2022.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/29/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
Objectives Coronavirus disease 2019 (COVID-19) has consumed many available resources within contingency plans, necessitating new capacity surges and novel approaches. This study aimed to explore the possibility of implementing the concept of flexible surge capacity to reduce the burden on hospitals by focussing on community resources to develop home isolation centres in Bangkok, Thailand. Study design A qualitative study consisted of observational and semi-structured interview data. Methods The development and activities of home isolation centres were observed, and interviews were conducted with leaders and operational workforces. Data were deductively analysed and categorised based on the practical elements necessary in disaster and emergency management. Results Data were categorised into the seven collaborative elements of the major incident medical management and support model. The command-and-control category demonstrated four subcategories: (1) coordination and collaboration; (2) staff engagement; (3) responsibility clarification; and (4) sustainability. Safety presented two subcategories: (1) patients' information privacy and treatment; and (2) personnel safety and privacy. Communication showed internal and external communications subcategories. Assessment, triage, treatment and transport followed the processes of the COVID-19 treatment protocols according to the World Health Organisation (WHO) guidelines and hospital operations. Several supply- and patient-related challenges were identified and managed during centre development. Conclusions The use of community resources, based on the flexible surge capacity concept, is feasible under restricted circumstances and reduced the burden on hospitals during the COVID-19 pandemic. Continuous education among multidisciplinary volunteer teams facilitated their full participation and engagement. The concept of flexible surge capacity may promote an alternative community-based care opportunity, irrespective of emergencies' aetiology.
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Abstract
Hospitals and health care systems with active critical care organizations (CCOs) that unified ICU units before the onset of the COVID-19 Pandemic were better positioned to adapt to the demands of the pandemic, due to their established standardization of care and integration of critical care within the larger structure of the hospital or health care system. CCOs should continue to make changes, based on the real experience of COVID-19 that would lead to improved care during the ongoing pandemic, and beyond.
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Affiliation(s)
- Samuel Rednor
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Jack D. Weiler Hospital, 1825 Eastchester Road, 4th Floor, Bronx, NY 10461, USA.
| | - Lewis A Eisen
- Division of Critical Care, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 201 East 87th Street, Apartment 15c, Bronx, NY 10467, USA
| | - J Perren Cobb
- Surgical Critical Care, Department of Surgery, Critical Care Institute, Keck Medicine of USC, Health Care Consultation Center, 1510 San Pablo Street #514, Los Angeles, CA 90033, USA; Surgical Critical Care, Department of Anesthesiology, Critical Care Institute, Keck Medicine of USC, Health Care Consultation Center, 1510 San Pablo Street #514, Los Angeles, CA 90033, USA
| | - Laura Evans
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, University of Washington Medical Center, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Craig M Coopersmith
- Department of Surgery, Emory Critical Care Center, 101 Woodruff Circle Suite WMB 5105, Atlanta, GA 30322, USA
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Chuang E, Grand-Clement J, Chen JT, Chan CW, Goyal V, Gong MN. Quantifying Utilitarian Outcomes to Inform Triage Ethics: Simulated Performance of a Ventilator Triage Protocol under Sars-CoV-2 Pandemic Surge Conditions. AJOB Empir Bioeth 2022; 13:196-204. [PMID: 35435803 DOI: 10.1080/23294515.2022.2063999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Equitable protocols to triage life-saving resources must be specified prior to shortages in order to promote transparency, trust and consistency. How well proposed utilitarian protocols perform to maximize lives saved is unknown. We aimed to estimate the survival rates that would be associated with implementation of the New York State 2015 guidelines for ventilator triage, and to compare them to a first-come-first-served triage method. METHODS We constructed a simulation model based on a modified version of the New York State 2015 guidelines compared to a first-come-first-served method under various hypothetical ventilator shortages. We included patients with SARs-CoV-2 infection admitted with respiratory failure requiring mechanical ventilation to three acute care hospitals in New York from 3/01/2020 and 5/27/2020. We estimated (1) survival rates, (2) number of excess deaths, (3) number of patients extubated early or not allocated a ventilator due to capacity constraints, (4) survival rates among patients not allocated a ventilator at triage or extubated early due to capacity constraints. RESULTS 807 patients were included in the study. The simulation model based on a modified New York State policy did not decrease mortality, excess death or exclusion from ventilators compared to the first-come-first-served policy at every ventilator capacity we tested using COVID-19 surge cohort patients. Survival rates were similar at all the survival probabilities estimated. At the lowest ventilator capacity, the modified New York State policy has an estimated survival of 28.5% (CI: 28.4-28.6), compared to 28.1% (CI: 27.7-28.5) for the first-come-first-served policy. CONCLUSIONS This simulation of a modified New York State guideline-based triage protocol revealed limitations in achieving the utilitarian goals these protocols are designed to fulfill. Quantifying these outcomes can inform a better balance among competing moral aims.
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Affiliation(s)
- Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | | | - Jen-Ting Chen
- Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Carri W Chan
- Decision, Risk, and Operations, Columbia Business School, New York, NY
| | - Vineet Goyal
- Industrial Engineering and Operations Research Department, Columbia University, New York, NY
| | - Michelle Ng Gong
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
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Zhou F, Deng J, Heybati K, Zuo QK, Ali S, Hou W, Wong CY, Ramaraju HB, Chang O, Dhivagaran T, Silver Z. Efficacy and safety of corticosteroid regimens for the treatment of hospitalized COVID-19 patients: a meta-analysis. Future Virol 2022; 17:463-489. [PMID: 35814934 PMCID: PMC9249165 DOI: 10.2217/fvl-2021-0244] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 04/08/2022] [Indexed: 12/15/2022]
Abstract
Aim To evaluate the efficacy and safety of corticosteroids for treating hospitalized COVID-19 patients. Materials & methods Efficacy outcomes included time to negative SARS-CoV-2 tests, length of stay, duration and incidence of intensive unit care stay, incidence of mortality and duration and incidence of mechanical ventilation. Safety outcomes included the incidence of adverse events and severe adverse events, incidence of hyperglycemia and incidence of nosocomial infections. Results Ninety-five randomized controlled trials (RCTs) and observational studies (n = 42,205) were included. Corticosteroids were associated with increased length of stay (based on RCT only), increased time to negative tests, decreased length of mechanical ventilation and increased odds of hyperglycemia. Conclusion Corticosteroids should be considered in patients requiring mechanical ventilation, and glycemic monitoring may be needed when administering corticosteroids.
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Affiliation(s)
- Fangwen Zhou
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Qi Kang Zuo
- Department of Anesthesiology, Rutgers, New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, USA
- Faculty of Science, McGill University, 845 Sherbrooke St W, Montreal, QC, H3A 0G5, Canada
| | - Saif Ali
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Wenteng Hou
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Chi Yi Wong
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | | | - Oswin Chang
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Thanansayan Dhivagaran
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
- Integrated Biomedical Engineering & Health Sciences Program (iBioMed), McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Zachary Silver
- Faculty of Science, Carleton University, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada
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