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

Impact of Benzodiazepines on Outcomes of Mechanically Ventilated Pediatric Intensive Care Patients: A Retrospective Cohort Study

IMPORTANCE

Benzodiazepines are the most frequently used sedatives in PICUs, but they are increasingly associated with negative outcomes. Understanding their impact on patient outcomes is critical to provide better sedative management for patients.

OBJECTIVE

Our objective was to determine the impact of midazolam and lorazepam on clinical outcomes among subjects requiring mechanical ventilation in the PICU. We hypothesized that subjects receiving benzodiazepines for tolerance of mechanical ventilation will demonstrate worse clinical outcomes when compared with those not receiving benzodiazepines.

DESIGN

Single-center, retrospective cohort study.

SETTING AND PARTICIPANTS

PICU of a tertiary-care medical center. One thousand fifty-four pediatric participants requiring invasive mechanical ventilation between June 2018 and December 2022. Participants were categorized into those who received benzodiazepine-inclusive sedation regimens (n = 747) and those who received nonbenzodiazepine regimens (n = 307).

INTERVENTIONS

None.

MAIN OUTCOMES AND MEASURES

Subjects were sorted into groups of benzodiazepine-sedative regimens (midazolam and lorazepam, only lorazepam) or nonbenzodiazepine-sedation regimens. The primary outcome was ventilator-free days (VFDs). Statistical analysis was performed using multivariable linear regression and propensity-score matching.

RESULTS

Subjects receiving continuous and/or intermittent benzodiazepines had fewer VFDs compared with the nonbenzodiazepine group (median 21.0 vs. 26.7; p < 0.001). The benzodiazepine group had fewer ICU-free and hospital-free days, higher delirium scores, and a greater need for withdrawal-tapering medications. This was redemonstrated in subjects only receiving intermittent benzodiazepines as well. Younger subjects were more likely to receive benzodiazepines.

CONCLUSIONS AND RELEVANCE

Our study demonstrates an association between children receiving both continuous and intermittent benzodiazepine sedation and worse clinical outcomes. These patients have fewer VFDs and longer length of stay, higher doses of nonbenzodiazepine sedatives, and increased need for withdrawal tapering medications and antipsychotics. It is unclear in this retrospective study if the outcomes were worse because the subjects received benzodiazepines or because subjects receiving benzodiazepines were sicker and thus required benzodiazepines in their analgosedative regimen. Further investigation is warranted into the impact of benzodiazepines on patient outcomes, nonpharmacologic management of sedation, improvement in bedside assessment of analgosedation, and optimal balance between over- and under-sedation.

Harnessing machine learning for predicting successful weaning from mechanical ventilation: A systematic review

BACKGROUND

Machine learning (ML) models represent advanced computational approaches with increasing application in predicting successful weaning from mechanical ventilation (MV). Whilst ML itself has a long history, its application to MV weaning outcomes has emerged more recently. In this systematic review, we assessed the effects of ML on the prediction of successful weaning outcomes amongst adult patients undergoing MV.

METHODS

PubMed, EMBASE, Scopus, Web of Science, and Google Scholar electronic databases were searched up to May 2024. In addition, ACM Digital Library and IEEE Xplore databases were searched. We included peer-reviewed studies examining ML models for the prediction of successful MV in adult patients. We used a modified version of the Joanna Briggs Institute checklist for quality assessment.

RESULTS

Eleven studies (n = 18 336) were included. Boosting algorithms, including extreme gradient boosting (XGBoost) and Light Gradient-Boosting Machine, were amongst the most frequently used methods, followed by random forest, multilayer perceptron, logistic regression, artificial neural networks, and convolutional neural networks, a deep learning model. The most common cross-validation methods included five-fold and 10-fold cross-validation. Model performance varied, with the artificial neural network accuracy ranging from 77% to 80%, multilayer perceptron achieving 87% accuracy and 94% precision, and convolutional neural network showing areas under the curve of 91% and 94%. XGBoost generally outperformed other models in the area under the curve comparisons. Quality assessment indicated that almost all studies had high quality as seven out of 10 studies had full scores.

CONCLUSIONS

ML models effectively predicted weaning outcomes in adult patients undergoing MV, with XGBoost outperforming other models. However, the absence of studies utilising newer architectures, such as transformer models, highlights an opportunity for further exploration and refinement in this field.

The Impact of Paroxysmal Sympathetic Hyperactivity on Prognosis in Patients with Severe Intracerebral Hemorrhage

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) is characterized by episodes of excessive sympathetic activity and is associated with poor outcomes in brain injuries, yet its impact on severe intracerebral hemorrhage (ICH) remains unclear. This study investigates the association between PSH and clinical outcomes in patients with severe ICH.

METHODS

We conducted a prospective observational cohort study of patients with severe ICH from January 2018 to December 2022. Severe ICH was defined as ICH with a Glasgow Coma Scale score ≤ 8 on admission, indicating significant neurological impairment. Patients were assessed for PSH using the PSH-Assessment Measure, and categorized into probable, possible, and unlikely PSH groups. Propensity score matching was used to adjust for baseline differences among three groups. The primary outcome was the 90-day mortality rate. Secondary outcomes included a favorable functional outcome at 90 days, defined by a modified Rankin Scale score of 0-2. Statistical analyses were performed using Cox proportional hazards regression and Kaplan-Meier survival analysis.

RESULTS

After propensity score matching, 177 patients (59 in each group) were analyzed. The 90-day mortality rate was significantly higher (P < 0.01) in the probable PSH group (67.8%), compared with possible (47.5%) and unlikely PSH groups (35.6%). The Kaplan-Meier survival curve further illustrates a significantly increased risk of 90-day mortality in the probable PSH group (Log rank test P < 0.01). Multivariate Cox proportional hazards regression analysis confirmed that, after adjusting for confounders, the presence of probable PSH (hazard ratio 3.86, 95% confidence interval 2.17-6.87; P < 0.01) was independently associated with a higher risk of 90-day mortality. Functional outcomes at 90 days were poorer in the probable PSH group.

CONCLUSIONS

Probable PSH is significantly associated with worse outcomes in severe ICH, underscoring the importance of early recognition and targeted management strategies.

Improving patient recruitment to randomised trials can be cost-effective: A case-study of dexamethasone from the RECOVERY trial

BACKGROUND

The RECOVERY trial assessed the effectiveness of treatments on preventing severe outcomes from COVID-19 disease in hospitalised patients from 176 NHS hospitals. Clinical benefits of Dexamethasone were observed for hospitalised COVID-19 patients. About 15% of all eligible patients were recruited into the trial. Had patient recruitment been higher the study would have been completed more rapidly.

AIM

To estimate the cost-effectiveness of improving recruitment to the RECOVERY trial from 15% to 50%, by employing or redeploying two research nurses to each hospital participating in the RECOVERY trial. The analysis is restricted to the evaluation of Dexamethasone versus No Dexamethasone.

METHODS

A decision tree model was developed to estimate the cost-effectiveness of Dexamethasone, against No Dexamethasone. Probability, utility, and cost inputs were used for each pathway and treatment. Then, a cost-utility analysis of clinical practice post-RECOVERY trial (83% Dexamethasone, 17% No Dexamethasone) versus previous clinical practice (100% No Dexamethasone) was undertaken; this analysis was aggregated at the population level and the cost of employing or redeploying two research nurses at each hospital was added, to estimate the cost-effectiveness of faster recruitment to the RECOVERY trial.

RESULTS

Faster recruitment to the RECOVERY trial could have generated an incremental net benefit of £13,955,476 related to the evaluation of Dexamethasone against No Dexamethasone, thus highlighting the magnitude of the foregone incremental net benefit due to not adopting a more cost-effective clinical practice (83% Dexamethasone, 17% No Dexamethasone) earlier. The findings remain robust following variations in the model's parameters, with a 85% and 94% probability of faster recruitment being cost-effective given a cost-effectiveness threshold of £20,000 and £30,000 per Quality Adjusted Life Year respectively.

CONCLUSION

Slow recruitment to randomised trials can have huge implications for healthcare systems as a result of not introducing a more cost-effective treatment earlier through faster patient recruitment.

Mechanical Ventilator Acquisition Strategy in a Large Private Tertiary Medical Center Using Monte Carlo Simulation

Background and Objective

Mechanical ventilators are essential albeit expensive equipment to support critically ill patients who have gone into respiratory failure. Adequate numbers should always be available to ensure that a hospital provides the optimal care to patients but the number of patients requiring them at any one time is unpredictable. Finding therefore the best balance in providing adequate ventilator numbers while ensuring the financial sustainability of a hospital is important.

Methods

A quantitative method using Monte Carlo Simulation was used to identify the optimal strategy for acquiring ventilators in a large private tertiary medical center in Metro Manila. The number of ventilators needed to provide ventilator needs 90% of the days per month (27/30) was determined using historical data on ventilator use over a period of four years. Four acquisition strategies were investigated: three ownership strategies (outright purchase, installment, and staggered purchase) and a rental strategy. Return on Investment (ROI), Internal Rate of Return (IRR), Modified Internal Rate of Return (MIRR), Net Present Value (NPV), and Payback period (or Breakeven Point) for each strategy were determined to help recommend the best strategy.A qualitative survey was also conducted among doctors, nurses, and respiratory therapists who were taking care of patients hooked to ventilators to find out their experiences comparing hospital-owned and rental ventilators.

Results

It was found that a total of 11 respirators were needed by the hospital to ensure that enough respirators were available for its patients at least 90% of the days in any month based on the previous four-year period. This meant acquiring three more ventilators as the hospital already owned eight. Among the strategies studied, projected over a 10-year period, the installment strategy (50% down payment with 0% interest over a 5-year period) proved to be the most financially advantageous with ROI = 9.36 times, IRR = 97% per year, MIRR = 26% per year, NPV = ₱39,324,297.60 and Payback period = 1.03 years). A more realistic installment strategy with 15% (paid quarterly or annually) and 25% annual interest rates were also explored with their financial parameters quite like but not as good as the 0% interest. The outright purchase of three ventilators came in lower (ROI = 4.53 times, IRR = 55% per year, MIRR = 19% per year, NPV = ₱38,064,297.60 and Payback period = 1.81 years) followed last by staggered purchase with ROI = 3.56 times, IRR = 64% per year, MIRR = 28% per year, NPV = ₱29,905,438.08, and payback period of 2.06 years. As there was no investment needed for the rental strategy, the only financial parameter available for it is the NPV which came out as ₱21,234,057.60.The qualitative part of the study showed that most of the healthcare workers involved in the care of patients attached to the ventilator were aware of the rental ventilators. The rental ventilators were generally described as of lower functionality and can more easily break down. The respondents almost uniformly expressed a preference for the hospital-owned ventilators.

Conclusion

This analysis showed that the best ventilator ownership strategy from a purely financial perspective for this hospital is by installment with a 50% down payment and 0% interest. Moderate rates of 15% and 25% interest per year were also good. These were followed by outright purchase and lastly by staggered purchase. The rental strategy gave the lowest cumulative 10-year income compared to any of the ownership strategies, but may still be considered good income because the hospital did not make any investment. However, it seems that most of the healthcare workers involved in taking care of patients on ventilators thought the rental ventilators were of lower quality and preferred the hospital-owned ventilators.

Prediction of prolonged mechanical ventilation in the intensive care unit via machine learning: a COVID-19 perspective

Early recognition of risk factors for prolonged mechanical ventilation (PMV) could allow for early clinical interventions, prevention of secondary complications such as nosocomial infections, and effective triage of hospital resources. This study tested the hypothesis that an ensemble machine learning (ML) analysis of clinical data at time of intubation could identify patients at risk of PMV, using a COVID-19 dataset to classify patients into PMV (> 14 days) and non-PMV (≤ 14 days) groups. While several factors are known to cause PMV, including acid-base, weakness, and delirium, lesser-utilized but routinely measured parameters such as platelet count, glucose levels and fevers may also be relevant. Patient data from a single University Hospital were analyzed via the ML workflow to predict patients at risk of PMV and identify key clinical markers. Model performance was evaluated on a chronologically distinct cohort. The ML workflow identified patients at risk of PMV with AUROCTRAIN=0.960 (F1TRAIN = 0.935) and AUROCTEST=0.804 (F1TEST = 0.800). Top key features for classification included glucose, platelet count, temperature, LVEF, bicarbonate (arterial blood gas), and BMI. Data analysis at intubation time via the proposed workflow offers the potential to accurately predict patients at risk of PMV, with the goal to improve patient management and triage of hospital resources.

Preoperative neurologic comorbidity and unanticipated early postoperative reintubation: a multicentre cohort study

BACKGROUND

The risk of respiratory complications is highest in the first 72 h post-surgery. Postoperative respiratory events can exacerbate pre-existing respiratory compromise and lead to reintubation of the trachea, particularly in patients with neurologic disorders. This study examined the association between neurologic comorbidities and unanticipated early postoperative reintubation in children.

METHODS

This multicentre, 1:1 propensity score-matched study included 420 096 children who underwent inpatient, elective, noncardiac surgery at National Surgical Quality Improvement Program reporting hospitals in 2012-22. The primary outcome was unanticipated early postoperative reintubation within 72 h after surgery. The secondary outcome was prolonged postoperative mechanical ventilation, defined as ventilator use >72 h. We also evaluated 30-day mortality in patients requiring reintubation.

RESULTS

Cerebral palsy was associated with the highest risk of early reintubation (adjusted relative risk [RRadj]: 1.97, 95% confidence interval [CI]: 1.44-2.69; P<0.01), followed by seizure disorders (RRadj: 1.87, 95% CI: 1.50-2.34; P<0.01), neuromuscular disorders (RRadj: 1.76, 95% CI: 1.41-2.19; P<0.01), and structural central nervous system abnormalities (RRadj: 1.35, 95% CI: 1.13-1.61; P<0.01). Unanticipated early postoperative reintubation was associated with an eight-times increased risk of 30-day mortality (adjusted hazard ratio: 8.1, 95% CI: 6.0-11.1; P<0.01). Risk of prolonged postoperative mechanical ventilation was also increased with neurologic comorbidities, particularly seizure disorders (RRadj: 1.73, 95% CI: 1.55-1.93; P<0.01).

CONCLUSIONS

Children with neurologic comorbidities have an increased risk of unanticipated early postoperative reintubation and prolonged mechanical ventilation. Given the high mortality risk associated with these outcomes, children with neurologic comorbidities require heightened monitoring and risk assessment.

Mortality and its associated factors among mechanically ventilated adult patients in the intensive care units of referral hospitals in Northwest Amhara, Ethiopia, 2023

Background

Worldwide, nearly half of the patients admitted to intensive care units require ventilatory support. Despite advances in intensive care unit patient management and mechanical ventilator utilization, the odds of mortality among mechanically ventilated patients are higher in resource-limited settings. Little is known about the mortality of patients on mechanical ventilation outside the capital of Ethiopia. This study aimed to assess mortality and its associated factors among mechanically ventilated adult patients in intensive care units.

Method

An institutional-based cross-sectional study was conducted on mechanically ventilated patients in intensive care units from 1 February 2020 to 1 March 2023. A simple random sampling technique was used to select 434 patients' charts. A data extraction tool designed on the Kobo toolbox, a smartphone data collection platform, was used to collect the data. The data were exported into Microsoft Excel 2019 and then into Stata 17 for data management and analysis. Descriptive statistics were used to summarize the characteristics of the study participants. A bivariable logistic regression was conducted, and variables with p ≤ 0.20 were recruited for multivariable analysis. Statistical significance was declared at p < 0.05, and the strength of associations was summarized using an adjusted odds ratio with 95% confidence intervals.

Result

A total of 404 charts of mechanically ventilated patients were included, with a completeness rate of 93.1%. The overall proportion of mortality was 62.87%, with a 95% CI of (58.16-67.58). In the multivariable logistic regression, age 41-70 years (AOR: 4.28, 95% CI: 1.89-9.62), sepsis (AOR: 2.43, 95% CI: 1.08-5.46), reintubation (AOR: 2.76, 95% CI: 1.06-7.21), and sedation use (AOR: 0.41, 95% CI: 0.18-0.98) were found to be significant factors associated with the mortality of mechanically ventilated patients in the intensive care unit.

Conclusion

The magnitude of mortality among mechanically ventilated patients was high. Factors associated with increased odds of death were advanced age, sepsis, and reintubation. However, sedation use was a factor associated with decreased mortality. Healthcare professionals in intensive care units should pay special attention to patients with sepsis, those requiring reintubation, those undergoing sedation, and those who are of advanced age.

Acupuncture reduces mechanical ventilation time in critically ill patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Mechanical Ventilation (MV) is an essential life support machine, frequently utilized in an Intensive Care Unit (ICU). Recently, a growing number of clinical trials have investigated the effect of acupuncture treatment on MV outcomes.

OBJECTIVES

This study investigated the safety and efficacy of acupuncture treatment for critically ill patients under MV.

METHODS

In this systematic review and meta-analysis of randomized controlled trials, the efficacy of acupuncture related interventions was compared to routine ICU treatments, and sham/control acupuncture as control interventions applied to ICU patients undergoing MV. The databases of PubMed, Cochrane Library, and Web of Science were extensively searched in the month of April 2022. The primary outcome measurements were defined as total MV time, ICU length of stay, and mortality. The Cochrane Collaboration risk of bias tool was employed to analyze the severity of bias. The meta-analysis was conducted using Review Manager 5.3 software. The quality of evidence was evaluated according to the GRADE approach.

RESULTS

A total of 10 clinical trials were included in this investigation. When comparing the performance of acupuncture-related interventions to that of the reported control interventions, the results of the meta-analysis revealed a significant reduction in the total number of MV days as well as the duration of ICU length of stay following acupuncture treatment (MD -2.06 [-3.33, -0.79] P = 0.001, I2 = 55 %, MD-1.26 [-2.00, -0.53] P = 0.0008, I2 = 77 %, respectively). A reduction in the total mortality was similarly observed (RR = 0.67 [0.47, 0.94] P = 0.02, I2 = 0 %).

CONCLUSION

This systematic review and meta-analysis identified a noteworthy reduction in the total MV days, time spent in the ICU, as well as the total mortality following acupuncture related interventions. However, the small sample size, risk of bias and existing heterogeneity should be taken into consideration. The results of this study are promising and further investigations in this field are warranted.

Gram-Negative ESKAPE Bacteria Surveillance in COVID-19 Pandemic Exposes High-Risk Sequence Types of Acinetobacter baumannii MDR in a Tertiary Care Hospital

The interruption of bacteriological surveillance due to the COVID-19 pandemic brought serious consequences, such as the collapse of health systems and the possible increase in antimicrobial resistance. Therefore, it is necessary to know the rate of resistance and its associated mechanisms in bacteria causing hospital infections during the pandemic. The aim of this work was to show the phenotypic and molecular characteristics of antimicrobial resistance in ESKAPE bacteria in a Mexican tertiary care hospital in the second and third years of the pandemic. For this purpose, during 2021 and 2022, two hundred unduplicated strains of the ESKAPE group (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii) were collected from various clinical sources and categorized by resistance according to the CLSI. An analysis of variance (ANOVA) complemented by the Tukey test was performed to search for changes in antimicrobial susceptibility profiles during the study period. Finally, the mechanisms of resistance involved in carbapenem resistance were analyzed, and the search for efflux pumps and high-risk sequence types in A. baumannii was performed by multilocus analysis (MLST). The results showed no changes in K. pneumoniae resistance during the period analyzed. Decreases in quinolone resistance were identified in E. coli (p = 0.039) and P. aeruginosa (p = 0.03). Interestingly, A. baumannii showed increases in resistance to penicillins (p = 0.004), aminoglycosides (p < 0.001, p = 0.027), carbapenems (p = 0.027), and folate inhibitors (p = 0.001). Several genes involved in carbapenem resistance were identified (blaNDM, blaVIM, blaOXA, blaKPC, blaOXA-40, and blaOXA-48) with a predominance of blaOXA-40 and the adeABCRS efflux pump in A. baumannii. Finally, MLST analysis revealed the presence of globally distributed sequence types (ST369 and ST758) related to hospital outbreaks in other parts of the world. The results presented demonstrate that the ESKAPE group has played an important role during the COVID-19 pandemic as nosocomial antibiotic-resistant pathogens and in particular A. baumannii MDR as a potential reservoir of resistance genes. The implications of the increases in antimicrobial resistance in pathogens of the ESKAPE group and mainly in A. baumannii during the COVID-19 pandemic are analyzed and discussed.

Estimating Australian Hospitalization Ratios and Costs for Wildtype SARS-CoV-2 in 2020

Utilizing a retrospective cohort study of SARS-CoV-2 wildtype (Wuhan) strain, we aimed to 1) utilize the unique Australian experience of temporarily eliminating SARS-CoV-2 to document and estimate the hospitalization demand; and 2) estimate the inpatient hospital costs associated with treatment. Case data was based on Victoria Australia from March 29 to December 31, 2020. Outcomes measures included hospitalization demand and case fatality ratio and inpatient hospitalization costs. Population adjusted results indicated that 10.2% (CI 9.9%-10.5%) required ward only admission, 1.0% (CI 0.9%-1.1%) required ICU admission plus 1.0% (CI 0.9%-1.1%) required ICU with mechanical ventilation. The overall case fatality ratio was 2.9% (CI 2.7%-3.1%). Mean ward only patient costs ranged from $22,714 to $57,100 per admission whilst ICU patient costs ranged from $37,228 to $140,455. With delayed, manageable outbreaks and public health measures leading to temporary elimination of community transmission, the Victorian COVID-19 data provides insight into initial pandemic severity and hospital costs.

Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis

OBJECTIVES

We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies.

DATA SOURCES

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted.

REVIEW METHODS

Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS.

RESULTS

The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference.

CONCLUSION

Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.

Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study

BACKGROUND

Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.

METHODS

We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.

RESULTS

Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).

CONCLUSIONS

We find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Early Tracheostomy May Reduce the Length of Hospital Stay

Introduction

There is evidence that prolonged invasive mechanical ventilation has negative consequences for critically ill patients and that performing tracheostomy (TQT) could help to reduce these consequences. The ideal period for performing TQT is still not clear in the literature since few studies have compared clinical aspects between patients undergoing early or late TQT.

Objective

To compare the mortality rate, length of stay in the intensive care unit, length of hospital stay, and number of days free of mechanical ventilation in patients undergoing TQT before or after ten days of orotracheal intubation.

Methods

A retrospective cohort study carried out by collecting data from patients admitted to an intensive care unit between January 2008 and December 2017. Patients who underwent TQT were divided into an early TQT group (i.e., time to TQT ≤ 10 days) or late TQT (i.e., time to TQT > 10 days) and the clinical outcomes of the two groups were compared.

Results

Patients in the early TQT group had a shorter ICU stay than the late TQT group (19 ± 16 vs. 32 ± 22 days, p < 0.001), a shorter stay in the hospital (42 ± 32 vs. 52 ± 50 days, p < 0.001), a shorter duration of mechanical ventilation (17 ± 14 vs. 30 ± 18 days, p < 0.001), and a higher proportion of survivors in the ICU outcome (57% vs. 46%, p < 0.001).

Conclusion

Tracheostomy performed within 10 days of mechanical ventilation provides several benefits to the patient and should be considered by the multidisciplinary team as a part of their clinical practice.

Clinical predictors and outcomes of pulmonary infarction in patients with central pulmonary embolism

BACKGROUND

Given the heterogeneity of predisposing factors associated with pulmonary infarction (PI) and the lack of clinically relevant outcomes among patients with acute pulmonary embolism (PE) complicated by PI, further investigation is required.

METHODS

Retrospective study of patients with central PE in an 11-year period. Data were stratified according to the diagnosis of PI. Multivariable logistic regression analysis was used to analyze factors associated with PI development and determine if PI was associated with severe hypoxemic respiratory failure and mechanical ventilation use.

RESULTS

Of 645 patients with central PE, 24% (n = 156) had PI. After adjusting for demographics, comorbidities, and clinical features on admission, only age (OR 0.98, CI 0.96-0.99; p = 0.008) was independently associated with PI. Regarding outcomes, 35% (n = 55) had severe hypoxemic respiratory failure, and 19% (n = 29) required mechanical ventilation. After adjusting for demographics, PE severity, and right ventricular dysfunction, PI was independently associated with severe hypoxemic respiratory failure (OR 1.78; CI 1.18-2.69, p = 0.005) and mechanical ventilation (OR 1.92; CI 1.14-3.22, p = 0.013).

CONCLUSIONS

Aging is a protective factor against PI. In acute central PE, subjects with PI had higher odds of developing severe hypoxemic respiratory failure and requiring mechanical ventilation.

Efficacy of a paper-based interleukin-6 test strip combined with a spectrum-based optical reader for sequential monitoring and early recognition of respiratory failure in elderly pneumonia-a pilot study

Introduction: Community-acquired pneumonia (CAP) is lethal in elderly individuals who are more vulnerable to respiratory failure and require more emergency ventilation support than younger individuals. Interleukin-6 (IL-6) plays a crucial role and has predictive value in CAP; high serum IL-6 concentrations in adults are associated with high respiratory failure and mortality rates. Early detection of IL-6 concentrations can facilitate the timely stratification of patients at risk of acute respiratory failure. However, conventional enzyme-linked immunosorbent assay (ELISA) IL-6 measurement is laborious and time-consuming. Methods: The IL-6 rapid diagnostic system combined with a lateral flow immunoassay-based (LFA-based) IL-6 test strip and a spectrum-based optical reader is a novel tool developed for rapid and sequential bedside measurements of serum IL-6 concentrations. Here, we evaluated the correlation between the IL-6 rapid diagnostic system and the ELISA and the efficacy of the system in stratifying high-risk elderly patients with CAP. Thirty-six elderly patients (median age: 86.5 years; range: 65-97 years) with CAP were enrolled. CAP diagnosis was established based on the Infectious Diseases Society of America (IDSA) criteria. The severity of pneumonia was assessed using the CURB-65 score and Pneumonia Severity Index (PSI). IL-6 concentration was measured twice within 24 h of admission. Results: The primary endpoint variable was respiratory failure requiring invasive mechanical or non-invasive ventilation support after admission. IL-6 rapid diagnostic readouts correlated with ELISA results (p < 0.0001) for 30 samples. Patients were predominantly male and bedridden (69.4%). Ten patients (27.7%) experienced respiratory failure during admission, and five (13.9%) died of pneumonia. Respiratory failure was associated with a higher mortality rate (p = 0.015). Decreased serum IL-6 concentration within 24 h after admission indicated a lower risk of developing respiratory failure in the later admission course (Receiver Operating Characteristic [ROC] curve = 0.696). Conclusion: Sequential IL-6 measurements with the IL-6 rapid diagnostic system might be useful in early clinical risk assessment and severity stratification of elderly patients with pneumonia. This system is a potential point-of-care diagnostic device for sequential serum IL-6 measurements that can be applied in variable healthcare systems.

Respiratory Monitoring During Mechanical Ventilation: The Present and the Future

The increased application of mechanical ventilation, the recognition of its harms and the interest in individualization raised the need for an effective monitoring. An increasing number of monitoring tools and modalities were introduced over the past 2 decades with growing insight into asynchrony, lung and chest wall mechanics, respiratory effort and drive. They should be used in a complementary rather than a standalone way. A sound strategy can guide a reduction in adverse effects like ventilator-induced lung injury, ventilator-induced diaphragm dysfunction, patient-ventilator asynchrony and helps early weaning from the ventilator. However, the diversity, complexity, lack of expertise, and associated cost make formulating the appropriate monitoring strategy a challenge for clinicians. Most often, a big amount of data is fed to the clinicians making interpretation difficult. Therefore, it is fundamental for intensivists to be aware of the principle, advantages, and limits of each tool. This analytic review includes a simplified narrative of the commonly used basic and advanced respiratory monitors along with their limits and future prospective.

Two-stage visual speech recognition for intensive care patients

In this work, we propose a framework to enhance the communication abilities of speech-impaired patients in an intensive care setting via reading lips. Medical procedure, such as a tracheotomy, causes the patient to lose the ability to utter speech with little to no impact on the habitual lip movement. Consequently, we developed a framework to predict the silently spoken text by performing visual speech recognition, i.e., lip-reading. In a two-stage architecture, frames of the patient's face are used to infer audio features as an intermediate prediction target, which are then used to predict the uttered text. To the best of our knowledge, this is the first approach to bring visual speech recognition into an intensive care setting. For this purpose, we recorded an audio-visual dataset in the University Hospital of Aachen's intensive care unit (ICU) with a language corpus hand-picked by experienced clinicians to be representative of their day-to-day routine. With a word error rate of 6.3%, the trained system reaches a sufficient overall performance to significantly increase the quality of communication between patient and clinician or relatives.

Comparative costs for critically ill patients with limited English proficiency versus English proficiency

OBJECTIVES

To conduct comparative cost analysis of hospital care for critically ill patients with Limited English Proficiency (LEP) versus patients with English proficiency (controls).

PATIENTS AND METHODS

We conducted a historical cohort study using propensity matching at Mayo Clinic Rochester, a quaternary care academic center. We included hospitalized patients who had at least one admission to ICU during a 10-year period between 1/1/2008-12/31/2017.

RESULTS

Due to substantial differences in baseline characteristics of the groups, propensity matching for the covariates age, sex, race, ethnicity, APACHE 3 score, and Charlson Comorbidity score was used, and we achieved the intended balance. The final cohort included 80,404 patients, 4,246 with LEP and 76,158 controls. Patients with LEP had higher costs during hospital admission to discharge, with a mean cost difference of $3861 (95% CI $822 to $6900, p = 0.013) and also higher costs during index ICU admission to hospital discharge, with a mean cost difference of $3166 (95% CI $231 to $6101, p = 0.035). A propensity matched cohort including only those that survived showed those with LEP had significantly greater mean costs for all outcomes. Sensitivity analysis revealed that international patients with LEP had significantly greater overall hospital costs of $9,240 than patients with LEP who resided in the US (95% CI $3341 to $15,140, p = 0.002).

CONCLUSION

This is the first study to demonstrate significantly higher costs for patients with LEP experiencing a critical illness. The causes for this may be increased healthcare utilization secondary to communication deficiencies that impede timely decision making about care.

Thrombocytopenia and Bloodstream Infection: Incidence and Implication on Length of Stay in the Pediatric Intensive Care Unit

The incidence and prognosis of thrombocytopenia in critically ill patients with bloodstream infection (BSI) is not well delineated in the pediatric intensive care unit (PICU) setting. We assessed these variables in our PICU and sought to determine whether thrombocytopenia could serve as a prognostic marker for length of stay (LOS). The study was conducted at the medical PICU of a university hospital, on all critically ill pediatric patients consecutively admitted during a 3-year period. Patient surveillance and data collection have been used to identify the risk factors during the study period. The main outcomes were BSI incidence and implication on morbidity and LOS. Data from 2,349 PICU patients was analyzed. The overall incidence of BSI was 3.9% (93/2,349). Overall, 85 of 93 patients (91.4%) with BSI survived and 8 patients died (8.6% mortality rate). The overall incidence of thrombocytopenia among these 93 patients was 54.8% (51/93) and 100% (8/8) for the nonsurvivors. Out of the 85 survivors, 27 thrombocytopenic patients were hospitalized for >14 days versus 14 of nonthrombocytopenic patients (p = 0.007). Thrombocytopenia was associated with borderline significance with an increased LOS (adjusted odds ratio = 3.00, 95% confidence interval: 0.93–9.71, p = 0.066). Thrombocytopenia is common in critically ill pediatric patients with BSI and constitutes a simple and readily available risk marker for PICU LOS.

Coronary artery bypass grafting versus stent implantation in patients with chronic coronary syndrome and left main disease: insights from a register throughout Germany

BACKGROUND

Recent randomized controlled trials have sparked debate about the optimal treatment of patients suffering from left main coronary artery disease. The present study analyzes outcomes of left main stenting versus coronary bypass grafting (CABG) in a nationwide registry in patients with chronic coronary syndrome (CCS).

METHODS

All cases suffering from CCS and left main coronary artery disease treated either with CABG or stent, were identified within the database of the German bureau of statistics. Logistic or linear regression models were used with 20 baseline patient characteristics as potential confounders to compare both regimens.

RESULTS

In 2018, 1318 cases with left main stenosis were treated with CABG and 8,920 with stent. Patients assigned for stenting were older (72.58 ± 9.87 vs. 68.63 ± 9.40, p < 0.001) and at higher operative risk, as assessed by logistic EuroSCORE (8.77 ± 8.45 vs. 4.85 ± 4.65, p < 0.001). After risk adjustment, no marked differences in outcomes were found for in-hospital mortality and stroke (risk adjusted odds ratio (aOR) for stent instead of CABG: aOR mortality: 1.08 [95% CI 0.66; 1.78], p = 0.748; aOR stroke: 0.59 [0.27; 1.32], p = 0.199). Stent implantation was associated with a reduced risk of relevant bleeding (aOR 0.38 [0.24; 0.61], p < 0.001), reduced prolonged ventilation time (aOR 0.54 [0.37 0.79], p = 0.002), and postoperative delirium (aOR 0.16 [0.11; 0.22], p < 0.001). Furthermore, stent implantation was associated with shorter hospital stay (- 6.78 days [- 5.86; - 7.71], p < 0.001) and lower costs (- €10,035 [- €11,500; - €8570], p < 0.001).

CONCLUSION

Left main stenting is a safe and effective treatment option for CCS-patients suffering from left main coronary artery disease at reasonable economic cost. Coronary artery bypass grafting versus stent implantation in patients with chronic coronary syndrome and left main disease: insights from a register throughout Germany. All cases with chronic coronary syndrome and left main stenosis treated in 2018 in Germany either with left main stenting or coronary bypass grafting were extracted from a nation-wide database. In-hospital outcomes were compared after logistic regression analysis.

Cost Analysis for Patients with Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit

The concept of improving the quality and safety of healthcare is well known. However, a follow-up question is often asked about whether these improvements are cost-effective. The prevalence of nosocomial infections (NIs) in the neonatal intensive care unit (NICU) is approximately 30% in developing countries. Ventilator-associated pneumonia (VAP) is the second most common NI in the NICU. Reducing the incidence of NIs can offer patients better and safer treatment and at the same time can provide cost savings for hospitals and payers. The aim of the study is to assess the direct costs of VAP in the NICU. This is a prospective study, conducted between January 2017 and June 2018 in the NICU of University Hospital “St. George” Plovdiv, Bulgaria. During this period, 107 neonates were ventilated for more than 48 h and included in the study. The costs for the hospital stay are based on the records from the Accounting Database of the setting. The differences directly attributable to VAP are presented both as an absolute value and percentage, based on the difference between the values of the analyzed variables. There are no statistically significant differences between patients with and without VAP in terms of age, sex, APGAR score, time of admission after birth and survival. We confirmed differences between the median birth weight (U = 924, p = 0.045) and average gestational age (t = 2.14, p = 0.035) of the patients in the two study groups. The median length of stay (patient-days) for patients with VAP is 32 days, compared to 18 days for non-VAP patients (U = 1752, p < 0.001). The attributive hospital stay due to VAP is 14 days. The median hospital costs for patients with VAP are estimated at €3675.77, compared to the lower expenses of €2327.78 for non-VAP patients (U = 1791.5, p < 0.001). The median cost for antibiotic therapy for patients with VAP is €432.79, compared to €351.61 for patients without VAP (U = 1556, p = 0.024). Our analysis confirms the results of other studies that the increased length of hospital stays due to VAP results in an increase in hospital costs. VAP is particularly associated with prematurity, low birth weight and prolonged mechanical ventilation.

Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative

BACKGROUND

Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7 days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU).

LOCAL PROBLEM

From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7 days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57).

METHODS

Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients.

INTERVENTIONS

In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app.

RESULTS

Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8 days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21 days) to 6 days (range: 1-15 days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008).

CONCLUSIONS

We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.

A Quality Improvement Initiative to Evaluate the Effectiveness of the ABCDEF Bundle on Sepsis Outcomes

Sepsis affects 1.7 million Americans annually and often requires an intensive care unit (ICU) stay. Survivors of ICU can experience long-term negative effects. This quality improvement initiative was designed to increase compliance with ABCDEF bundle elements and improve clinical outcomes. A significant improvement was seen in the completion of spontaneous awakening and breathing trials (P = .002), delirium assessment (P = .041), and early mobility (P = .000), which was associated with a reduction in mortality and 30-day readmission rates. Findings were consistent with other research that demonstrated an improvement in care delivery and some clinical outcomes.

Characteristics and resource utilization of high-cost users in the intensive care unit: a population-based cohort study

Background

Healthcare expenditure within the intensive care unit (ICU) is costly. A cost reduction strategy may be to target patients accounting for a disproportionate amount of healthcare spending, or high-cost users. This study aims to describe high-cost users in the ICU, including health outcomes and cost patterns.

Methods

We conducted a population-based retrospective cohort study of patients with ICU admissions in Ontario from 2011 to 2018. Patients with total healthcare costs in the year following ICU admission (including the admission itself) in the upper 10th percentile were defined as high-cost users. We compared characteristics and outcomes including length of stay, mortality, disposition, and costs between groups.

Results

Among 370,061 patients included, 37,006 were high-cost users. High-cost users were 64.2 years old, 58.3% male, and had more comorbidities (41.2% had ≥3) when likened to non-high cost users (66.1 years old, 57.2% male, 27.9% had ≥3 comorbidities). ICU length of stay was four times greater for high-cost users compared to non-high cost users (22.4 days, 95% confidence interval [CI] 22.0–22.7 days vs. 5.56 days, 95% CI 5.54–5.57 days). High-cost users had lower in-hospital mortality (10.0% vs.14.2%), but increased dispositioning outside of home (77.4% vs. 42.2%) compared to non-high-cost users. Total healthcare costs were five-fold higher for high-cost users ($238,231, 95% CI $237,020–$239,442) compared to non-high-cost users ($45,155, 95% CI $45,046–$45,264). High-cost users accounted for 37.0% of total healthcare costs.

Conclusion

High-cost users have increased length of stay, lower in-hospital mortality, and higher total healthcare costs when compared to non-high-cost users. Further studies into cost patterns and predictors of high-cost users are necessary to identify methods of decreasing healthcare expenditure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07318-y.

Practical Review of Mechanical Ventilation in Adults and Children in The Operating Room and Emergency Department

BACKGROUND

During general anesthesia, mechanical ventilation can cause pulmonary damage through mechanism of ventilator-induced lung injury which is a major cause of postoperative pulmonary complications, which varies between 5 and 33% and increases significantly the 30-day mortality of the surgical patient.

OBJECTIVE

The aim of this review is to analyze different variables which played key role in safe application of mechanical ventilation in the operating room and emergency setting.

METHOD

Also, we wanted to analyze different types of population that underwent intraoperative mechanical ventilation like obese patients, pediatric and adult population and different strategies such as one lung ventilation and ventilation in trendelemburg position. The peer-reviewed articles analyzed were selected according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) from Pubmed/Medline, Ovid/Wiley and Cochrane Library, combining key terms such as: "pulmonary post-operative complications", "protective ventilation", "alveolar recruitment maneuvers", "respiratory compliance", "intraoperative paediatric ventilation", "best peep", "types of ventilation". Among the 230 papers identified, 150 articles were selected, after title - abstract examination and removing the duplicates, resulting in 94 articles related to mechanical ventilation in operating room and emergency setting that were analyzed.

RESULTS

Careful preoperative patient's evaluation and protective ventilation (i.e. use of low tidal volumes, adequate PEEP and alveolar recruitment maneuvers) has been shown to be effective not only in limiting alveolar de-recruitment, alveolar overdistension and lung damage, but also in reducing the onset of pulmonary post-operative complications (PPCs).

CONCLUSION

Mechanical ventilation is like "Janus Bi-front" because it is essential for surgical procedures, for the care of critical care patients and in life-threatening conditions but it can be harmful to the patient if continued for a long time and where an excessive dose of oxygen is administered into the lungs. Low tidal volume is associated with minor rate of PPCs and other complications and every complication can increase length of Stay, adding cost to NHS between 1580 € and 1650 € per day in Europe and currently the prevention of PPCS is only weapon that we possess.

Enhanced recovery in liver transplantation: A value-based approach to complex surgical care

BACKGROUND

Value-based healthcare focuses on improving outcomes relative to cost. We aimed to study the impact of an enhanced recovery pathway for liver transplant recipients on providing value.

METHODS

In total, 379 liver recipients were identified: pre-enhanced recovery pathway (2017, n = 57) and post-enhanced recovery pathway (2018-2020, n = 322). The enhanced recovery pathway bundle was defined through multidisciplinary efforts and included optimal fluid management, end-of-case extubation, multimodal analgesia, and a standardized care pathway. Pre- and post-enhanced recovery pathway patients were compared with regard to extubation rates, lengths of stay, complications, readmissions, survival, and costs.

RESULTS

Pre- and post-enhanced recovery pathway recipient model for end-stage liver disease score and balance of risk scores were similar, although post-enhanced recovery pathway recipients had a higher median donor risk index (1.55 vs 1.39, P = .003). End-of-case extubation rates were 78% post-enhanced recovery pathway (including 91% in 2020) versus 5% pre-enhanced recovery pathway, with post-enhanced recovery pathway patients having decreased median intraoperative transfusion requirements (1,500 vs 3,000 mL, P < .001). Post-enhanced recovery pathway recipients had shorter median intensive care unit (1.6 vs 2.3 days, P = .01) and hospital stays (5.4 vs 8.0 days, P < .001). Incidence of severe (Clavien-Dindo ≥3) complications during the index hospitalization were similar between pre-enhanced recovery pathway versus post-enhanced recovery pathway groups (33% vs 23%, P = .13), as were 30-day readmissions (26% vs 33%, P = .44) and 1-year survival (93.0% vs 94.5%, P = .58). The post-enhanced recovery pathway cohort demonstrated a significant reduction in median direct cost per case ($11,406; P < .001).

CONCLUSION

Implementation of an enhanced recovery pathway in liver transplantation is feasible, safe, and effective in delivering value, even in the setting of complex surgical care.

Contemporary Trends and Outcomes of Prosthetic Valve Infective Endocarditis in the United States: Insights from the Nationwide Inpatient Sample

BACKGROUND

Prosthetic valve endocarditis (PVE) carries high mortality and morbidity as compared to native valve endocarditis (NVE). Contemporary data on PVE are lacking, we aimed to study contemporary trends, outcomes, and burden of PVE using nationally representative data.

METHODS

We used the National Inpatient Sample from 2000 to 2017 to identify patients admitted with PVE using ICD-9-CM and ICD-10 codes. Risk-adjusted rates were calculated using an Analysis of Covariance (ANCOVA) with the Generalized Linear Model (GLM). Trends were assessed with linear regression and Pearson's Chi-square when appropriate. Binomial logistic regression was used to assess predictors of in-hospital mortality.

RESULTS

We identified 43,602 hospitalizations for PVE. PVE hospitalizations increased from 1803 in 2000 to 3450 in 2017. Risk-adjusted mortality decreased from 10.7% in 2002 to 7.3% in 2017 (P<0.01). Logistic regression analysis on mortality showed increase association with age (OR, 1.021, 95%CI [1.017-1.024], p<0.01), Hispanics (OR, 1.493, 95%CI [1.296-1.719], p<0.01) and patients with drug abuse(OR, 1.233, 95%CI [1.05-1.449], p=0.01). Co-morbid conditions like congestive heart failure (OR, 1.511, 95%CI [1.366-1.673], p<0.01), renal failure (OR, 1.572, 95%CI [1.427-1.732], p<0.01) and weight loss (OR, 1.425, 95%CI [1.093-1.419], p<0.01) were also associated with higher mortality.

CONCLUSIONS

Over the years the adjusted in-hospital mortality in PVE has trended down but the average cost of stay has increased despite decrease in length of stay.

Implementation of High-Flow Nasal Cannula Therapy Outside the Intensive Care Setting

BACKGROUND

High-flow nasal cannula (HFNC) is an option for respiratory support in patients with acute hypoxic respiratory failure. To improve patient outcomes, reduce ICU-associated costs, and ease ICU bed availability, a multi-phased, comprehensive strategy was implemented to make HFNC available outside the ICU under the supervision of pulmonology or trauma providers in cooperation with a dedicated respiratory therapy team. The purpose of this study was to describe the education and implementation process for initiating HFNC therapy outside the ICU and to convey key patient demographics and outcomes from the implementation period.

METHODS

HFNC therapy was implemented at a tertiary hospital in the Midwest, with systematic roll-out to all in-patient floors over a 9-month period. Utilization of the therapy and patient outcomes were tracked to ensure safety and efficacy of the effort.

RESULTS

During the implementation period, 346 unique subjects met study inclusion criteria. Median (interquartile range) hospital length of stay was 8 d (4-12), and median duration of HFNC therapy was 44 h (18-90). Two thirds of subjects (n = 238) received the entire course of HFNC therapy outside the ICU, and more than half of subjects (n = 184) avoided the ICU for their entire hospitalization. Moreover, 6% of subjects in the study group escalated from HFNC to noninvasive ventilation, and 5% of subjects escalated from HFNC to mechanical ventilation.

CONCLUSIONS

A comprehensive implementation process and a robust therapy protocol were integral to initiating and managing HFNC in all hospital locations. Study findings indicate that patients with acute hypoxic respiratory failure can safely receive HFNC therapy outside the ICU with appropriate patient selection and staff education.

Evaluation of the Perceived Barriers and Facilitators to Timely Extubation of Critically Ill Adults: An Interprofessional Survey

BACKGROUND

Spontaneous breathing trials (SBTs) are an evidence-based way of identifying patients ready for mechanical ventilation (MV) liberation. Despite their effectiveness, global SBT performance rates remain suboptimal, and many patients who demonstrate the ability to breathe on their own remain on MV. The factors that influence clinicians' decision to discontinue MV following a successful SBT remain unclear.

AIMS

The aim of this study was to explore the underlying causes of extubation delays in the intensive care unit (ICU) from an interprofessional perspective.

METHODS

An exploratory, descriptive, cross-sectional design was used. An online survey was administered in December 2019 to clinicians practicing in three ICUs at a single medical center in the U.S. Survey questions focused on clinicians' perceptions of current MV liberation practices and perceived barriers or facilitators to timely extubation after a successful SBT.

RESULTS

Of 425 eligible clinicians, 135 completed the survey (31.7% response rate). The majority of clinicians believed the current SBT and extubation process took too long (n = 108; 80.0%) and that this delay negatively affected patient outcomes. While professional groups differed in their rankings of importance, factors perceived to contribute to extubation delays most commonly included SBT timing, low provider confidence levels in making extubation decisions, and patient-specific factors. Potential strategies to overcome these barriers included developing an automated extubation protocol, performing SBTs when the provider responsible for final extubation decisions is physically present, and decreasing clinician perception of reprimand or condemnation for failed extubations.

LINKING EVIDENCE TO ACTION

The MV liberation process is complex and dependent on the decisions of various ICU professionals. Clinicians perceive a number of potentially modifiable provider- and organizational-level factors that cause extubation delays in everyday practice. Understanding and addressing these barriers is essential for improving ICU quality and patient outcomes. Future research should explore the effect of nurse and respiratory therapist-driven extubation protocols on MV liberation rates.

Incremental Costs Associated with Length of Hospitalization Due to Viral Pneumonia: Impact of Intensive Care and Economic Implications of Reducing the Length of Stay in the Era of COVID-19

BACKGROUND

Emerging trial data for treatment of COVID-19 suggest that in addition to improved clinical outcomes, these treatments reduce length of hospital stay (LOS). However, the economic value of a shortened LOS is unclear.

OBJECTIVE

To estimate incremental costs per day of hospitalization for a patient with influenza or viral pneumonia, as a proxy for COVID-19; ICU costs associated with invasive mechanical ventilation (iMV) were also determined.

METHODS

Retrospective analysis of claims-based data was conducted using the IBM MarketScan® Commercial Claims and Encounters and Medicare Supplemental and Coordination of Care and the Medicare Fee-for-Service claims databases for hospitalizations due to influenza/viral pneumonia between January 2018 and June 2019. Cases were stratified as uncomplicated hospitalizations or with ICU. Ordinary least squares regression, excluding LOS or costs exceeding the 99th percentile (base case), was used to estimate incremental costs per day; a sensitivity analysis included all qualified hospitalizations. Additional sensitivity analyses used weighting methodology.

RESULTS

Among 6055 and 118,419 hospitalizations in the commercially insured and Medicare databases, respectively, 5958 and 116,552 hospitalizations, respectively, represented the base case. Estimated incremental base case costs per additional inpatient day were $2158 and $3900 in the commercial population for uncomplicated hospitalizations and hospitalizations with ICU, respectively, and $475 and $668, respectively in the Medicare population. Estimated incremental base case costs per additional ICU day were $5254 and $608 for Commercial and Medicare populations, respectively. Higher absolute costs were estimated in the sensitivity analysis on all qualified hospitalizations; the weighted sensitivity analyses generally showed that estimates were stable. Use of iMV increased costs by $35,482 and $13,101 in the commercial and Medicare populations, respectively.

CONCLUSION

The incremental daily cost of a hospitalization is substantial for US patients with commercial insurance and for Medicare patients. These findings may help quantify the economic value of COVID-19 treatments that reduce LOS.

Is it infection or rather vascular inflammation? Game-changer insights and recommendations from patterns of multi-organ involvement and affected subgroups in COVID-19

Coronavirus disease 2019 (COVID-19) is a serious illness that has rapidly spread throughout the globe. The seriousness of complications puts significant pressures on hospital resources, especially the availability of ICU and ventilators. Current evidence suggests that COVID-19 pathogenesis majorly involves microvascular injury induced by hypercytokinemia, namely interleukin 6 (IL-6). We recount the suggested inflammatory pathway for COVID-19 and its effects on various organ systems, including respiratory, cardiac, hematologic, reproductive, and nervous organ systems, as well examine the role of hypercytokinemia in the at-risk geriatric and obesity subgroups with upregulated cytokines' profile. In view of these findings, we strongly encourage the conduction of prospective studies to determine the baseline levels of IL-6 in infected patients, which can predict a negative outcome in COVID-19 cases, with subsequent early administration of IL-6 inhibitors, to decrease the need for ICU admission and the pressure on healthcare systems. Video abstract: http://links.lww.com/CAEN/A24.