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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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Álvarez-Macías A, Úbeda-Iglesias A, Macías-Seda J, Gómez-Salgado J. Factors related to mortality of patients with COVID-19 who are admitted to the ICU: Prognostic mortality factors of COVID-19 patients. Medicine (Baltimore) 2024; 103:e38266. [PMID: 38787973 PMCID: PMC11124599 DOI: 10.1097/md.0000000000038266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
During the severe acute respiratory syndrome coronavirus 2 pandemic, hospital resources, particularly critical care units, were overburdened and this had a significant impact on both the therapies and the prognosis of these patients. This study aimed to identify factors and therapies that may improve prognosis and other factors associated with increased mortality. A secondary objective was to evaluate the impact that obesity had on these patients. An observational study was conducted on 482 patients aged 18 years or older who were diagnosed with SARS-CoV-2 pneumonia and admitted to the Intensive Care Units of 3 national hospitals registered in the CIBERESUCICOVID database between September 2020 and March 2021. After identifying the sample profile, risk factors were analyzed, the predictive model was constructed, and crude odd ratios were calculated for each factor. Additionally, logistic regression was used to build the multivariate model adjusting for potential confounders. The final model included only the variables selected using the Backward method. A sample of 335 men (69.5%) and 145 women (30.08%) aged 61.94 ± 12.75 years with a body mass index (BMI) of 28.05 (25.7; 31.2) was obtained. A total of 113 patients received noninvasive mechanical ventilation. The most common comorbidities were: high blood pressure (51.04%), obesity (28%), diabetes mellitus (23.44%), other metabolic diseases (21.16%), chronic heart failure (18.05%), chronic obstructive pulmonary disease (11.62%), and chronic kidney disease (10.16%). In-hospital, 3-month and 6-month post-discharge mortality in patients with BMI > 30 (n = 135) versus BMI ≤ 30 (n = 347) was significantly different (P = .06). Noninvasive mechanical ventilation failed in 42.4% of patients with BMI > 30 compared to 55% of patients with BMI ≤ 30. This study identified the factors associated with failure of mechanical ventilation. The most common comorbidities were congestive heart failure, high blood pressure, chronic kidney disease, severe liver disease, diabetes mellitus, and solid organ transplantation. In terms of ventilatory support, patients who received high-flow nasal oxygen therapy on admission had lower mortality rates. The use of renal replacement therapy was also significantly associated with higher mortality.
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Affiliation(s)
| | | | - Juana Macías-Seda
- Área de Gestión Sanitaria Campo de Gibraltar Oeste, Hospital Punta de Europa, Algeciras, Spain
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, Huelva, Spain
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil, Ecuador
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Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024; 28:424-435. [PMID: 38738199 PMCID: PMC11080105 DOI: 10.5005/jp-journals-10071-24696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 05/14/2024] Open
Abstract
Background and aim While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. Methods There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. Results About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Conclusion Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians. How to cite this article Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.
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Affiliation(s)
- Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Rutula N Sonawane
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Jignesh Shah
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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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 2024:10.1007/s12630-024-02744-y. [PMID: 38589739 DOI: 10.1007/s12630-024-02744-y] [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: 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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Nates JL, Oropello JM, Badjatia N, Beilman G, Coopersmith CM, Halpern NA, Herr DL, Jacobi J, Kahn R, Leung S, Puri N, Sen A, Pastores SM. Flow-Sizing Critical Care Resources. Crit Care Med 2023; 51:1552-1565. [PMID: 37486677 DOI: 10.1097/ccm.0000000000005967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVES To describe the factors affecting critical care capacity and how critical care organizations (CCOs) within academic centers in the U.S. flow-size critical care resources under normal operations, strain, and surge conditions. DATA SOURCES PubMed, federal agency and American Hospital Association reports, and previous CCO survey results were reviewed. STUDY SELECTION Studies and reports of critical care bed capacity and utilization within CCOs and in the United States were selected. DATA EXTRACTION The Academic Leaders in the Critical Care Medicine Task Force established regular conference calls to reach a consensus on the approach of CCOs to "flow-sizing" critical care services. DATA SYNTHESIS The approach of CCOs to "flow-sizing" critical care is outlined. The vertical (relation to institutional resources, e.g., space allocation, equipment, personnel redistribution) and horizontal (interdepartmental, e.g., emergency department, operating room, inpatient floors) integration of critical care delivery (ICUs, rapid response) for healthcare organizations and the methods by which CCOs flow-size critical care during normal operations, strain, and surge conditions are described. The advantages, barriers, and recommendations for the rapid and efficient scaling of critical care operations via a CCO structure are explained. Comprehensive guidance and resources for the development of "flow-sizing" capability by a CCO within a healthcare organization are provided. CONCLUSIONS We identified and summarized the fundamental principles affecting critical care capacity. The taskforce highlighted the advantages of the CCO governance model to achieve rapid and cost-effective "flow-sizing" of critical care services and provide recommendations and resources to facilitate this capability. The relevance of a comprehensive approach to "flow-sizing" has become particularly relevant in the wake of the latest COVID-19 pandemic. In light of the growing risks of another extreme epidemic, planning for adequate capacity to confront the next critical care crisis is urgent.
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Affiliation(s)
- Joseph L Nates
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | | - Nitin Puri
- Cooper University Health Care, Camden, NJ
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Larangeira AS, Mezzaroba AL, Morakami FK, Cardoso LTQ, Matsuo T, Grion CMC. Improved performance of an intensive care unit after changing the admission triage model. Sci Rep 2023; 13:17043. [PMID: 37813948 PMCID: PMC10562408 DOI: 10.1038/s41598-023-44184-6] [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: 03/18/2023] [Accepted: 10/04/2023] [Indexed: 10/11/2023] Open
Abstract
The aim of this study is to analyze the effect of implementing a prioritization triage model for admission to an intensive care unit on the outcome of critically ill patients. Retrospective longitudinal study of adult patients admitted to the Intensive Care Unit (ICU) carried out from January 2013 to December 2017. The primary outcome considered was vital status at hospital discharge. Patients were divided into period 1 (chronological triage) during the years 2013 and 2014 and period 2 (prioritization triage) during the years 2015-2017. A total of 1227 patients in period 1 and 2056 in period 2 were analyzed. Patients admitted in period 2 were older (59.8 years) compared to period 1 (57.3 years; p < 0.001) with less chronic diseases (13.6% vs. 19.2%; p = 0.001), and higher median APACHE II score (21.0 vs. 18.0; p < 0.001)) and TISS 28 score (28.0 vs. 27.0; p < 0.001). In period 2, patients tended to stay in the ICU for a shorter time (8.5 ± 11.8 days) compared to period 1 (9.6 ± 16.0 days; p = 0.060) and had lower mortality at ICU (32.8% vs. 36.9%; p = 0.016) and hospital discharge (44.2% vs. 47.8%; p = 0.041). The change in the triage model from a chronological model to a prioritization model resulted in improvement in the performance of the ICU and reduction in the hospital mortality rate.
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Affiliation(s)
| | - Ana Luiza Mezzaroba
- Internal Medicine Department, Londrina State University, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil
| | | | - Lucienne T Q Cardoso
- Internal Medicine Department, Londrina State University, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil
| | - Tiemi Matsuo
- Statistics Department, Londrina State University, Londrina, Brazil
| | - Cintia M C Grion
- Internal Medicine Department, Londrina State University, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil.
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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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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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Beresford S, Tandon A, Farina S, Johnston B, Crews M, Welters ID. Who to escalate during a pandemic? A retrospective observational study about decision-making during the COVID-19 pandemic in the UK. Emerg Med J 2023:emermed-2022-212505. [PMID: 37328261 DOI: 10.1136/emermed-2022-212505] [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: 04/06/2022] [Accepted: 06/05/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Optimal decision-making regarding who to admit to critical care in pandemic situations remains unclear. We compared age, Clinical Frailty Score (CFS), 4C Mortality Score and hospital mortality in two separate COVID-19 surges based on the escalation decision made by the treating physician. METHODS A retrospective analysis of all referrals to critical care during the first COVID-19 surge (cohort 1, March/April 2020) and a late surge (cohort 2, October/November 2021) was undertaken. Patients with confirmed or high clinical suspicion of COVID-19 infection were included. A senior critical care physician assessed all patients regarding their suitability for potential intensive care unit admission. Demographics, CFS, 4C Mortality Score and hospital mortality were compared depending on the escalation decision made by the attending physician. RESULTS 203 patients were included in the study, 139 in cohort 1 and 64 in cohort 2. There were no significant differences in age, CFS and 4C scores between the two cohorts. Patients deemed suitable for escalation by clinicians were significantly younger with significantly lower CFS and 4C scores compared with patients who were not deemed to benefit from escalation. This pattern was observed in both cohorts. Mortality in patients not deemed suitable for escalation was 61.8% in cohort 1 and 47.4% in cohort 2 (p<0.001). CONCLUSIONS Decisions who to escalate to critical care in settings with limited resources pose moral distress on clinicians. 4C score, age and CFS did not change significantly between the two surges but differed significantly between patients deemed suitable for escalation and those deemed unsuitable by clinicians. Risk prediction tools may be useful in a pandemic to supplement clinical decision-making, even though escalation thresholds require adjustments to reflect changes in risk profile and outcomes between different pandemic surges.
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Affiliation(s)
- Stephanie Beresford
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Aditi Tandon
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sofia Farina
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Brian Johnston
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
| | - Maryam Crews
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ingeborg Dorothea Welters
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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Quality of Life in COVID-Related ARDS Patients One Year after Intensive Care Discharge (Odissea Study): A Multicenter Observational Study. J Clin Med 2023; 12:jcm12031058. [PMID: 36769705 PMCID: PMC9918008 DOI: 10.3390/jcm12031058] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Investigating the health-related quality of life (HRQoL) after intensive care unit (ICU) discharge is necessary to identify possible modifiable risk factors. The primary aim of this study was to investigate the HRQoL in COVID-19 critically ill patients one year after ICU discharge. METHODS In this multicenter prospective observational study, COVID-19 patients admitted to nine ICUs from 1 March 2020 to 28 February 2021 in Italy were enrolled. One year after ICU discharge, patients were required to fill in short-form health survey 36 (SF-36) and impact of event-revised (IES-R) questionnaire. A multivariate linear or logistic regression analysis to search for factors associated with a lower HRQoL and post-traumatic stress disorded (PTSD) were carried out, respectively. RESULTS Among 1003 patients screened, 343 (median age 63 years [57-70]) were enrolled. Mechanical ventilation lasted for a median of 10 days [2-20]. Physical functioning (PF 85 [60-95]), physical role (PR 75 [0-100]), emotional role (RE 100 [33-100]), bodily pain (BP 77.5 [45-100]), social functioning (SF 75 [50-100]), general health (GH 55 [35-72]), vitality (VT 55 [40-70]), mental health (MH 68 [52-84]) and health change (HC 50 [25-75]) describe the SF-36 items. A median physical component summary (PCS) and mental component summary (MCS) scores were 45.9 (36.5-53.5) and 51.7 (48.8-54.3), respectively, considering 50 as the normal value of the healthy general population. In all, 109 patients (31.8%) tested positive for post-traumatic stress disorder, also reporting a significantly worse HRQoL in all SF-36 domains. The female gender, history of cardiovascular disease, liver disease and length of hospital stay negatively affected the HRQoL. Weight at follow-up was a risk factor for PTSD (OR 1.02, p = 0.03). CONCLUSIONS The HRQoL in COVID-19 ARDS (C-ARDS) patients was reduced regarding the PCS, while the median MCS value was slightly above normal. Some risk factors for a lower HRQoL have been identified, the presence of PTSD is one of them. Further research is warranted to better identify the possible factors affecting the HRQoL in C-ARDS.
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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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Abstract
OBJECTIVES Here, we report the management of a catastrophic COVID-19 Delta variant surge, which overloaded ICU capacity, using crisis standards of care (CSC) based on a multiapproach protocol. DESIGN Retrospective observational study. SETTING University Hospital of Guadeloupe. PATIENTS This study retrospectively included all patients who were hospitalized for COVID-19 pneumonia between August 11, 2021, and September 10, 2021, and were eligible for ICU admission. INTERVENTION Based on age, comorbidities, and disease severity, patients were assigned to three groups: Green (ICU admission as soon as possible), Orange (ICU admission after the admission of all patients in the Green group), and Red (no ICU admission). MEASUREMENTS AND MAIN RESULTS Among the 328 patients eligible for ICU admission, 100 (30%) were assigned to the Green group, 116 (35%) to the Orange group, and 112 (34%) to the Red group. No patient in the Green group died while waiting for an ICU bed, whereas 14 patients (12%) in the Orange group died while waiting for an ICU bed. The 90-day mortality rates were 24%, 37%, and 78% in the Green, Orange, and Red groups, respectively. A total of 130 patients were transferred to the ICU, including 79 from the Green group, 51 from the Orange group, and none from the Red group. Multivariate analysis revealed that among patients admitted to the ICU, death was independently associated with a longer time between ICU referral and ICU admission, the Sequential Organ Failure Assessment score, and the number of comorbidities, but not with triage group. CONCLUSIONS CSC based on a multiapproach protocol allowed admission of all patients with a good prognosis. Higher mortality was associated with late admission, rather than triage group.
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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] [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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Na YS, Kim JH, Baek MS, Kim WY, Baek AR, Lee BY, Seong GM, Lee SI. In-hospital mortality prediction using frailty scale and severity score in elderly patients with severe COVID-19. Acute Crit Care 2022; 37:303-311. [PMID: 35791648 PMCID: PMC9475168 DOI: 10.4266/acc.2022.00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background Elderly patients with coronavirus disease 2019 (COVID-19) have a high disease severity and mortality. However, the use of the frailty scale and severity score to predict in-hospital mortality in the elderly is not well established. Therefore, in this study, we investigated the use of these scores in COVID-19 cases in the elderly. Methods This multicenter retrospective study included severe COVID-19 patients admitted to seven hospitals in Korea from February 2020 to February 2021. We evaluated patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II score; confusion, urea nitrogen, respiratory rate, blood pressure, 65 years of age and older (CURB-65) score; modified early warning score (MEWS); Sequential Organ Failure Assessment (SOFA) score; clinical frailty scale (CFS) score; and Charlson comorbidity index (CCI). We evaluated the predictive value using receiver operating characteristic (ROC) curve analysis. Results The study included 318 elderly patients with severe COVID-19 of whom 237 (74.5%) were survivors and 81 (25.5%) were non-survivors. The non-survivor group was older and had more comorbidities than the survivor group. The CFS, CCI, APACHE II, SOFA, CURB-65, and MEWS scores were higher in the non-survivor group than in the survivor group. When analyzed using the ROC curve, SOFA score showed the best performance in predicting the prognosis of elderly patients (area under the curve=0.766, P<0.001). CFS and SOFA scores were associated with in-hospital mortality in the multivariate analysis. Conclusions The SOFA score is an efficient tool for assessing in-hospital mortality in elderly patients with severe COVID-19.
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Altın Z, Buran F. Attitudes of health professionals toward elderly patients during the COVID-19 pandemic. Aging Clin Exp Res 2022; 34:2567-2576. [PMID: 35986878 PMCID: PMC9391638 DOI: 10.1007/s40520-022-02209-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/20/2022] [Indexed: 11/15/2022]
Abstract
The perceptions and attitudes of health professionals toward a certain group of society are among the factors affecting the quality of health service. This study aimed to investigate the attitudes of physicians and nurses about ageism in the COVID-19 pandemic. An easy face-to-face survey was used to collect the data. It involves the questions about demographic information and geriatric perspectives, and they were taken from the University of California at Los Angeles Geriatrics Attitudes Scale (UCLA-GAS). In the study, 58.1% of participants were over 35 years old, 76.6% were women, and 50% were physicians out of 308 in total. It was found that most of the participants have worked in inpatient services and intensive care units for the longest time, where the triage issue was the most discussed topic during the pandemic. An average of 75% of the participants stated that they did not witness any ageist attitude in health care provided. In the comparative analyses conducted with the UCLA-GAS sub-dimensions, statistically significant results, which were anti-ageist and prioritized human life, were obtained. In the extraordinary periods such as pandemic, especially physicians should be able to give the treatment without feeling any social or legal concerns during their medical applications with the light of guidelines accepted scientifically, legally, and morally. Thus, health professionals will not only be away from legal concerns such as malpractice but also will not be exhausted mentally and they can provide more sufficient health service by working under these conditions.
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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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Lung Ultrasound to Assist ICU Admission Decision-Making Process of COVID-19 Patients With Acute Respiratory Failure. Crit Care Explor 2022; 4:e0719. [PMID: 35765373 PMCID: PMC9225487 DOI: 10.1097/cce.0000000000000719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Prendki V, Tiseo G, Falcone M. Caring for older adults during the COVID-19 pandemic. Clin Microbiol Infect 2022; 28:785-791. [PMID: 35283306 PMCID: PMC8912971 DOI: 10.1016/j.cmi.2022.02.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/15/2022] [Accepted: 02/24/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Elderly patients represent a high-risk group with increased risk of death from COVID-19. Despite the number of published studies, several unmet needs in care for older adults exist. OBJECTIVES To discuss unmet needs of COVID-19 in this special population. SOURCES A literature review for studies on COVID-19 in elderly patients published between December 2019 and November 2021 was performed. Clinical questions were formulated to guide the literature search. The search was conducted in the MEDLINE database, combining specific search terms. Two reviewers independently conducted the search and selected the studies according to the prespecified clinical questions. CONTENT Elderly patients with COVID-19 have peculiar characteristics. They may have atypical clinical presentation, with no fever and with delirium or neurological manifestations as the most common signs, with potential delayed diagnosis and increased risk of death. The reported fatality rates among elderly patients with COVID-19 are extremely high. Several factors, including comorbidities, atypical presentation, and exclusion from intensive care unit care, contribute to this excess of mortality. Age alone is frequently used as a key factor to exclude the elderly from intensive care, but there is evidence that frailty rather than age better predicts the risk of poor outcome in this category. Durability of vaccine efficacy in the elderly remains debated, and the need for a third booster dose is becoming increasingly evident. Finally, efforts to care for elderly patients who have survived after acute COVID-19 should be implemented, considering the high rates of long COVID sequelae and the risk of longitudinal functional and cognitive decline. IMPLICATIONS We highlight peculiar aspects of COVID-19 in elderly patients and factors contributing to high risk of poor outcome in this category. We also illuminated gaps in current evidence, suggesting future research directions and underlining the need for further studies on the optimal management of elderly patients with COVID-19.
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Affiliation(s)
- Virginie Prendki
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
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20
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Galdeano Lozano M, Alfaro Álvarez JC, Parra Macías N, Salas Campos R, Heili Frades S, Montserrat JM, Rosell Gratacós A, Abad Capa J, Parra Ordaz O, López Seguí F. Effectiveness of Intermediate Respiratory Care Units as an Alternative to Intensive Care Units during the COVID-19 Pandemic in Catalonia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106034. [PMID: 35627571 PMCID: PMC9141338 DOI: 10.3390/ijerph19106034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/28/2022]
Abstract
Objectives: During the COVID-19 pandemic, the risk of collapse for the health system created great difficulties. We will demonstrate that intermediate respiratory care units (IRCU) provide adequate management of patients with non-invasive respiratory support, which is particularly important for patients with SARS-CoV-2 pneumonia. Methods: A prospective observational study of patients with COVID-19 admitted to the ICU of a tertiary hospital. Sociodemographic data, comorbidities, pharmacological, respiratory support, laboratory and blood gas variables were collected. The overall cost of the unit was subsequently analyzed. Results: 991 patients were admitted, 56 to the IRCU (from a of 81 admitted to the critical care unit). Mean age was 65 years (SD 12.8), Barthel index 75 (SD 8.3), Charlson comorbidity index 3.1 (SD 2.2), HTN 27%, COPD 89% and obesity 24%. A significant relationship (p < 0.05) with higher mortality was noted for the following parameters: fever greater than or equal to 39 °C [OR 5.6; 95% CI (1.2−2.7); p = 0.020], protocolized pharmacological treatment [OR 0.3; 95% CI (0.1−0.9); p = 0.023] and IOI [OR 3.7; 95% CI (1.1−12.3); p = 0.025]. NIMV had less of a negative impact [OR 1.8; 95% CI (0.4−8.4); p = 0.423] than IOI. The total cost of the IRCU amounted to €66,233. The cost per day of stay in the IRCU was €164 per patient. The total cost avoided was €214,865. Conclusions: The pandemic has highlighted the importance of IRCUs in facilitating the management of a high patient volume. The treatment carried out in IRCUs is effective and efficient, reducing both admissions to and stays in the ICU.
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Affiliation(s)
- Marina Galdeano Lozano
- Unidad de Ventilación y Cuidados Respiratorios Intermedios, Servicio de Neumología, Direcció Clínica Àrea del Tórax, Hospital Universitari Germans Trias i Pujol, IGTP, Universitat Autónoma de Barcelona, Reseau Europén de Recherche en Ventilation Artificielle (REVA), 08193 Barcelona, Spain
- Unidad de Economía de la Salud, Dirección de Innovación de la Gerencia Territorial Metropolitana Norte, Institut Català de la Salut, 08007 Barcelona, Spain;
- Doctorat de Medicina i Recerca Translacional, Facultat de Medicina, Universitat de Barcelona, 08193 Barcelona, Spain;
- Correspondence: ; Tel.: +34-934661200 (ext. 3603)
| | | | - Núria Parra Macías
- Unidad de Innovación Clínica y Promoción de la Salud, Hospital Universitario Sagrat Cor, Grupo Quirón Salud, 08029 Barcelona, Spain;
| | - Rosario Salas Campos
- Servicio de Medicina Interna, Hospital Universitario Sagrat Cor, Quirón Salud, 08029 Barcelona, Spain;
| | - Sarah Heili Frades
- Unidad de Cuidados Intermedios Respiratorios, Hospital Fundación Jimenez Díaz, Grupo Quirón Salud, Reseau Europén de Recherche en Ventilation Artificielle, 28040 Madrid, Spain;
| | - Josep Maria Montserrat
- Unidad del Sueño, Servicio de Neumología, Hospital Clínic Provincial Barcelona, Universitat de Barcelona, 08193 Barcelona, Spain;
| | - Antoni Rosell Gratacós
- Servicio de Neumología, Direcció Clínica Àrea del Tórax, Hospital Universitari Germans Trias i Pujol, IGTP, Universitat Autónoma de Barcelona, 08193 Barcelona, Spain; (A.R.G.); (J.A.C.)
| | - Jorge Abad Capa
- Servicio de Neumología, Direcció Clínica Àrea del Tórax, Hospital Universitari Germans Trias i Pujol, IGTP, Universitat Autónoma de Barcelona, 08193 Barcelona, Spain; (A.R.G.); (J.A.C.)
| | - Olga Parra Ordaz
- Doctorat de Medicina i Recerca Translacional, Facultat de Medicina, Universitat de Barcelona, 08193 Barcelona, Spain;
- Unidad de Sueño Servicio de Neumología, Hospital Universitario Sagrat Cor, Quirón Salud, 08029 Barcelona, Spain
| | - Francesc López Seguí
- Unidad de Economía de la Salud, Dirección de Innovación de la Gerencia Territorial Metropolitana Norte, Institut Català de la Salut, 08007 Barcelona, Spain;
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Postelnicu R, Mukherjee V, Uppal A, Hick JL. Maintaining Standards of Care in the Era of Special Pathogens. Health Secur 2022; 20:S107-S113. [PMID: 35575728 DOI: 10.1089/hs.2021.0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Radu Postelnicu
- Radu Postelnicu, MD, is Associate Director, Medical ICU; at NYC Health + Hospitals/Bellevue, New York, NY. Radu Postelnicu is also Assistant Professors of Medicine; at NYU Grossman School of Medicine, New York, NY
| | - Vikramjit Mukherjee
- Vikramjit Mukherjee, MD, FRCP (Edin), is Director, Medical ICU; at NYC Health + Hospitals/Bellevue, New York, NY. Vikramjit Mukherjee is also Assistant Professors of Medicine; at NYU Grossman School of Medicine, New York, NY
| | - Amit Uppal
- Amit Uppal, MD, is Director, Critical Care; at NYC Health + Hospitals/Bellevue, New York, NY. Amit Uppal is an Associate Professor of Medicine; at NYU Grossman School of Medicine, New York, NY
| | - John L Hick
- John L. Hick, MD, is a Faculty Emergency Physician, Hennepin Healthcare, and a Professor of Emergency Medicine, University of Minnesota, Minneapolis, MN
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Vetrugno L, Deana C, Maggiore SM. COVID-19 Hurricane: Recovering the Worldwide Health System with the RE.RE.RE. (REsponse–REstoration–REengineering) Approach—Who Will Get There First? Healthcare (Basel) 2022; 10:healthcare10040602. [PMID: 35455780 PMCID: PMC9029496 DOI: 10.3390/healthcare10040602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 02/01/2023] Open
Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy;
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, 66100 Chieti, Italy;
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Venezia Giulia, 33100 Udine, Italy
- Correspondence: ; Tel.: +39-333-374-5660
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, 66100 Chieti, Italy;
- Department of Innovative Technologies in Medicine and Dentistry, Gabriele d’Annunzio University of ChietiPescara, 66100 Chieti, Italy
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Ethical Lessons from an Intensivist's Perspective. J Clin Med 2022; 11:jcm11061613. [PMID: 35329939 PMCID: PMC8949962 DOI: 10.3390/jcm11061613] [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: 02/12/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/17/2022] Open
Abstract
Intensive care units (ICUs) around the world have been hugely impacted by the SARS-CoV-2 pandemic and the vast numbers of patients admitted with COVID-19, requiring respiratory support and prolonged stays. This pressure, with resulting shortages of ICU beds, equipment, and staff has raised ethical dilemmas as physicians have had to determine how best to allocate the sparse resources. Here, we reflect on some of the major ethical aspects of the COVID-19 pandemic, including resource allocation and rationing, end-of-life decision-making, and communication and staff support. Importantly, these issues are regularly faced in non-pandemic ICU patient management and useful lessons can be learned from the discussions that have occurred as a result of the COVID-19 situation.
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Hippocrates and prophecies: the unfulfilled promise of prediction rules. Can J Anaesth 2022; 69:289-292. [PMID: 35099773 PMCID: PMC8802535 DOI: 10.1007/s12630-021-02164-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
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Riviello ED, Dechen T, O’Donoghue AL, Cocchi MN, Hayes MM, Molina RL, Moraco NH, Mosenthal A, Rosenblatt M, Talmor N, Walsh DP, Sontag DN, Stevens JP. Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19. JAMA Netw Open 2022; 5:e221744. [PMID: 35289860 PMCID: PMC8924715 DOI: 10.1001/jamanetworkopen.2022.1744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. OBJECTIVE To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. EXPOSURES Race, ethnicity, Social Vulnerability Index. MAIN OUTCOMES AND MEASURES The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. RESULTS Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. CONCLUSIONS AND RELEVANCE In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.
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Affiliation(s)
- Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashley L. O’Donoghue
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael N. Cocchi
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rose L. Molina
- Harvard Medical School, Boston, Massachusetts
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicole H. Moraco
- Division of General Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Anne Mosenthal
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Michael Rosenblatt
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Noa Talmor
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel P. Walsh
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Critical Care, Beth Israel Deaconess Hospital–Plymouth, Plymouth, Massachusetts
| | - David N. Sontag
- Harvard Medical School, Boston, Massachusetts
- Office of the General Counsel, Beth Israel Lahey Health, Cambridge, Massachusetts
- Ethics Advisory Committee, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer P. Stevens
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Adverse Perinatal Outcomes in COVID-19 Infected Pregnant Women: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10020203. [PMID: 35206820 PMCID: PMC8871986 DOI: 10.3390/healthcare10020203] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 01/27/2023] Open
Abstract
The impact of COVID-19 virus infection during pregnancy is still unclear. This systematic review and meta-analysis aimed to quantitatively pool the evidence on impact of COVID-19 infection on perinatal outcomes. Databases of Medline, Embase, and Cochrane library were searched using the keywords related to COVID-19 and perinatal outcomes from December 2019 to 30 June 2021. Observational studies comparing the perinatal outcomes of COVID-19 infection in pregnancy with a non-infected comparator were included. The screening process and quality assessment of the included studies were performed independently by two reviewers. Meta-analyses were used to pool the comparative dichotomous data on perinatal outcomes. The database search yielded 4049 results, 1254 of which were duplicates. We included a total of 21 observational studies that assessed the adverse perinatal outcomes with COVID-19 infection. The odds of maternal death (pooled OR: 7.05 [2.41−20.65]), preeclampsia (pooled OR: 1.39 [1.29−1.50]), cesarean delivery (pooled OR: 1.67 [1.29−2.15]), fetal distress (pooled OR: 1.66 [1.35−2.05]), preterm birth (pooled OR: 1.86 [1.34−2.58]), low birth weight (pooled OR: 1.69 [1.35−2.11]), stillbirth (pooled OR: 1.46 [1.16−1.85]), 5th minute Apgar score of less than 7 (pooled OR: 1.44 [1.11−1.86]) and admissions to neonatal intensive care unit (pooled OR: 2.12 [1.36−3.32]) were higher among COVID-19 infected pregnant women compared to non-infected pregnant women.
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Béraud G, Timsit JF, Leleu H. Remdesivir and dexamethasone as tools to relieve hospital care systems stressed by COVID-19: A modelling study on bed resources and budget impact. PLoS One 2022; 17:e0262462. [PMID: 35020746 PMCID: PMC8754316 DOI: 10.1371/journal.pone.0262462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 12/22/2021] [Indexed: 12/15/2022] Open
Abstract
Remdesivir and dexamethasone are the only drugs providing reductions in the lengths of hospital stays for COVID-19 patients. We assessed the impacts of remdesivir on hospital-bed resources and budgets affected by the COVID-19 outbreak. A stochastic agent-based model was combined with epidemiological data available on the COVID-19 outbreak in France and data from two randomized control trials. Strategies involving treating with remdesivir only patients with low-flow oxygen and patients with low-flow and high-flow oxygen were examined. Treating all eligible low-flow oxygen patients during the entirety of the second wave would have decreased hospital-bed occupancy in conventional wards by 4% [2%; 7%] and intensive care unit (ICU)-bed occupancy by 9% [6%; 13%]. Extending remdesivir use to high-flow-oxygen patients would have amplified reductions in ICU-bed occupancy by up to 14% [18%; 11%]. A minimum remdesivir uptake of 20% was required to observe decreases in bed occupancy. Dexamethasone had effects of similar amplitude. Depending on the treatment strategy, using remdesivir would, in most cases, generate savings (up to 722€) or at least be cost neutral (an extra cost of 34€). Treating eligible patients could significantly limit the saturation of hospital capacities, particularly in ICUs. The generated savings would exceed the costs of medications.
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Affiliation(s)
- Guillaume Béraud
- Infectious Diseases Department, University Hospital of Poitiers, Poitiers, France
| | - Jean-François Timsit
- APHP- Bichat Hospital—Medical and Infectious Diseases Intensive Care Unit, Paris, France
- IAME UMR 1137 Université de Paris (Paris-Diderot), Paris, France
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Rednor S, Eisen LA, Cobb JP, Evans L, Coopersmith CM. Critical Care Response During the COVID-19 Pandemic. Crit Care Clin 2022; 38:623-637. [PMID: 35667747 PMCID: PMC8747943 DOI: 10.1016/j.ccc.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abbasi-Kangevari M, Arshi S, Hassanian-Moghaddam H, Kolahi AA. Public Opinion on Priorities Toward Fair Allocation of Ventilators During COVID-19 Pandemic: A Nationwide Survey. Front Public Health 2022; 9:753048. [PMID: 34970524 PMCID: PMC8712311 DOI: 10.3389/fpubh.2021.753048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/23/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The rapidly growing imbalance between supply and demand for ventilators during the COVID-19 pandemic has highlighted the principles for fair allocation of scarce resources. Failing to address public views and concerns on the subject could fuel distrust. The objective of this study was to determine the priorities of the Iranian public toward the fair allocation of ventilators during the COVID-19 pandemic. Methods: This anonymous community-based national study was conducted from May 28 to Aug 20, 2020, in Iran. Data were collected via the Google Forms platform, using an online self-administrative questionnaire. The questionnaire assessed participants' assigned prioritization scores for ventilators based on medical and non-medical criteria. To quantify participants' responses on prioritizing ventilator allocation among sub-groups of patients with COVID-19 who need mechanical ventilation scores ranging from -2, very low priority, to +2, very high priority were assigned to each response. Results: Responses of 2,043 participants, 1,189 women, and 1,012 men, were analyzed. The mean (SD) age was 31.1 (9.5), being 32.1 (9.3) among women, and 29.9 (9.6) among men. Among all participants, 274 (13.4%) were healthcare workers. The median of assigned priority score was zero (equal) for gender, age 41-80, nationality, religion, socioeconomic, high-profile governmental position, high-profile occupation, being celebrities, employment status, smoking status, drug abuse, end-stage status, and obesity. The median assigned priority score was +2 (very high priority) for pregnancy, and having <2 years old children. The median assigned priority score was +1 (high priority) for physicians and nurses of patients with COVID-19, patients with nobel research position, those aged <40 years, those with underlying disease, immunocompromise status, and malignancy. Age>80 was the only factor participants assigned -1 (low priority) to. Conclusions: Participants stated that socioeconomic factors, except for age>80, should not be involved in prioritizing mechanical ventilators at the time of resources scarcity. Front-line physicians and nurses of COVID-19 patients, pregnant mothers, mothers who had children under 2 years old were given high priority.
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Affiliation(s)
- Mohsen Abbasi-Kangevari
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahnam Arshi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Pereira JFDS, Carvalho RHDSBFD, Pinho JRO, Thomaz EBAF, Lamy ZC, Soares RD, Santos JMCDF, Britto e Alves MTSSD. CHALLENGES AT THE FRONT: EXPERIENCES OF PROFESSIONALS IN ADMITTING PATIENTS TO THE INTENSIVE CARE UNIT DURING THE COVID-19 PANDEMIC. TEXTO & CONTEXTO ENFERMAGEM 2022. [DOI: 10.1590/1980-265x-tce-2022-0196en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
ABSTRACT Objective: to know the perspectives, practices and challenges in decision-making for admitting patients into the Intensive Care Unit during the Covid-19 pandemic. Methods: a qualitative study developed in two public hospitals in Maranhão, Brazil, from November/2020 to January/2021. Data collection took place through individual interviews guided by a script. A total of 22 professionals participated in the study: nurses and doctors who worked in the Intensive Care Unit and Bed Regulation in the first wave of the pandemic. Content Analysis was used in the thematic mode, with support from the Qualitative Data Analysis software program for data categorization. The theory of Responsibility for Reasonableness guided the study. Results: two main categories emerged: “The context of the decision-making process - the paradox of celestial discharges” and “Decision-making for admission”. In the scenario of high demand, a lack of beds, and the uncertainties of the “new disease”, deciding who would occupy the bed was arduous and conflicting. Clinical and non-clinical criteria such as severity, chance of survival, distance to be covered and transport conditions were considered. It was found that the ambivalence of feelings attributed to death and care at that moment of the pandemic marked the social and technical environment of intensive care. Conclusions: the complexity of the decision-making process for admission to an intensive care unit was evidenced, demonstrating the importance of analyzing the allocation of critical resources in pandemic scenarios. Knowing the perspectives of professionals and their reflections on the experiences in that period can help in planning the allocation of health resources in future emergency scenarios.
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Karlafti E, Anagnostis A, Kotzakioulafi E, Vittoraki MC, Eufraimidou A, Kasarjyan K, Eufraimidou K, Dimitriadou G, Kakanis C, Anthopoulos M, Kaiafa G, Savopoulos C, Didangelos T. Does COVID-19 Clinical Status Associate with Outcome Severity? An Unsupervised Machine Learning Approach for Knowledge Extraction. J Pers Med 2021; 11:1380. [PMID: 34945852 PMCID: PMC8705973 DOI: 10.3390/jpm11121380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
Since the beginning of the COVID-19 pandemic, 195 million people have been infected and 4.2 million have died from the disease or its side effects. Physicians, healthcare scientists and medical staff continuously try to deal with overloaded hospital admissions, while in parallel, they try to identify meaningful correlations between the severity of infected patients with their symptoms, comorbidities and biomarkers. Artificial intelligence (AI) and machine learning (ML) have been used recently in many areas related to COVID-19 healthcare. The main goal is to manage effectively the wide variety of issues related to COVID-19 and its consequences. The existing applications of ML to COVID-19 healthcare are based on supervised classifications which require a labeled training dataset, serving as reference point for learning, as well as predefined classes. However, the existing knowledge about COVID-19 and its consequences is still not solid and the points of common agreement among different scientific communities are still unclear. Therefore, this study aimed to follow an unsupervised clustering approach, where prior knowledge is not required (tabula rasa). More specifically, 268 hospitalized patients at the First Propaedeutic Department of Internal Medicine of AHEPA University Hospital of Thessaloniki were assessed in terms of 40 clinical variables (numerical and categorical), leading to a high-dimensionality dataset. Dimensionality reduction was performed by applying a principal component analysis (PCA) on the numerical part of the dataset and a multiple correspondence analysis (MCA) on the categorical part of the dataset. Then, the Bayesian information criterion (BIC) was applied to Gaussian mixture models (GMM) in order to identify the optimal number of clusters under which the best grouping of patients occurs. The proposed methodology identified four clusters of patients with similar clinical characteristics. The analysis revealed a cluster of asymptomatic patients that resulted in death at a rate of 23.8%. This striking result forces us to reconsider the relationship between the severity of COVID-19 clinical symptoms and the patient's mortality.
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Affiliation(s)
- Eleni Karlafti
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
- Emergency Department, AHEPA University Hospital, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece
| | - Athanasios Anagnostis
- Advanced Insights, Artificial Intelligence Solutions, Ipsilantou 10, Panorama, 55236 Thessaloniki, Greece;
| | - Evangelia Kotzakioulafi
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Michaela Chrysanthi Vittoraki
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Ariadni Eufraimidou
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Kristine Kasarjyan
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Katerina Eufraimidou
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Georgia Dimitriadou
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Chrisovalantis Kakanis
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Michail Anthopoulos
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Georgia Kaiafa
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Christos Savopoulos
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
| | - Triantafyllos Didangelos
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital of Thessaloniki, 54621 Thessaloniki, Greece; (E.K.); (M.C.V.); (A.E.); (K.K.); (K.E.); (G.D.); (C.K.); (M.A.); (G.K.); (C.S.); (T.D.)
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Brinkman S, Termorshuizen F, Dongelmans DA, Bakhshi-Raiez F, Arbous MS, de Lange DW, de Keizer NF. Comparison of outcome and characteristics between 6343 COVID-19 patients and 2256 other community-acquired viral pneumonia patients admitted to Dutch ICUs. J Crit Care 2021; 68:76-82. [PMID: 34929530 PMCID: PMC8683137 DOI: 10.1016/j.jcrc.2021.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 10/12/2021] [Accepted: 12/05/2021] [Indexed: 01/08/2023]
Abstract
Purpose Describe the differences in characteristics and outcomes between COVID-19 and other viral pneumonia patients admitted to Dutch ICUs. Materials and methods Data from the National-Intensive-Care-Evaluation-registry of COVID-19 patients admitted between February 15th and January 1th 2021 and other viral pneumonia patients admitted between January 1st 2017 and January 1st 2020 were used. Patients' characteristics, the unadjusted, and adjusted in-hospital mortality were compared. Results 6343 COVID-19 and 2256 other viral pneumonia patients from 79 ICUs were included. The COVID-19 patients included more male (71.3 vs 49.8%), had a higher Body-Mass-Index (28.1 vs 25.5), less comorbidities (42.2 vs 72.7%), and a prolonged hospital length of stay (19 vs 9 days). The COVID-19 patients had a significantly higher crude in-hospital mortality rate (Odds ratio (OR) = 1.80), after adjustment for patient characteristics and ICU occupancy rate the OR was respectively 3.62 and 3.58. Conclusion Higher mortality among COVID-19 patients could not be explained by patient characteristics and higher ICU occupancy rates, indicating that COVID-19 is more severe compared to other viral pneumonia. Our findings confirm earlier warnings of a high need of ICU capacity and high mortality rates among relatively healthy COVID-19 patients as this may lead to a higher mental workload for the staff.
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Affiliation(s)
- S Brinkman
- National Intensive Care Evaluation (NICE) Foundation, Postbus 23640, 1100 EC Amsterdam, the Netherlands; Amsterdam UMC location AMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - F Termorshuizen
- National Intensive Care Evaluation (NICE) Foundation, Postbus 23640, 1100 EC Amsterdam, the Netherlands; Amsterdam UMC location AMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - D A Dongelmans
- National Intensive Care Evaluation (NICE) Foundation, Postbus 23640, 1100 EC Amsterdam, the Netherlands; Amsterdam UMC location AMC, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - F Bakhshi-Raiez
- National Intensive Care Evaluation (NICE) Foundation, Postbus 23640, 1100 EC Amsterdam, the Netherlands; Amsterdam UMC location AMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - M S Arbous
- National Intensive Care Evaluation (NICE) Foundation, Postbus 23640, 1100 EC Amsterdam, the Netherlands; Leiden University Medical Center, Department of Intensive Care Medicine, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - D W de Lange
- National Intensive Care Evaluation (NICE) Foundation, Postbus 23640, 1100 EC Amsterdam, the Netherlands; University Medical Center, University of Utrecht, Department of Intensive Care Medicine, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - N F de Keizer
- National Intensive Care Evaluation (NICE) Foundation, Postbus 23640, 1100 EC Amsterdam, the Netherlands; Amsterdam UMC location AMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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Raper R. The implications of living with COVID-19 for intensive care in Australia. Med J Aust 2021; 215:511-512. [PMID: 34766344 PMCID: PMC8661781 DOI: 10.5694/mja2.51332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022]
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Tian YJA. The Ethical Unjustifications of COVID-19 Triage Committees. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:621-628. [PMID: 34964927 PMCID: PMC8715149 DOI: 10.1007/s11673-021-10132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/05/2021] [Indexed: 06/14/2023]
Abstract
The ever-debated question of triage and allocating the life-saving ventilator during the COVID-19 pandemic has been repeatedly raised and challenged within the ethical community after shortages propelled doctors before life and death decisions (Anderson-Shaw and Zar 2020; Huxtable 2020; Jongepier 2020; Peterson, Largent, and Karlawish 2020). The British Medical Association's ethical guidance highlighted the possibility of an initial surge of patients that would outstrip the health system's ability to deliver care "to existing standards," where utilitarian measures have to be applied, and triage decisions need to maximize "overall benefit" (British Medical Association 2020, 3) In these emergency circumstances, triage that "grades according to their needs and the probable outcomes of intervention" will prioritize or eliminate patients for treatment, and health professionals may be faced with obligations to withhold or withdraw treatments to some patients in favour of others (British Medical Association 2020, 4). This piece is a response and extension to articles published on the manner of involvement for ethics and ethicists in pandemic triage decisions, particularly examining the ability and necessity of establishing triage committees to ameliorate scarce allocation decisions for physicians.
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Affiliation(s)
- Yi Jiao Angelina Tian
- Institute for Biomedical Ethics, University of Basel, Bernouillistrasse 28, CH-4056, Basel, Switzerland.
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Associations of Government-issued ICU Admission Criteria with Clinical Practices, Outcomes, and ICU Bed Occupancy. Ann Am Thorac Soc 2021; 19:1013-1021. [PMID: 34813412 DOI: 10.1513/annalsats.202107-844oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE In Japan, the government officially issued intensive care unit (ICU) admission criteria that require ICU units to admit patients who need a certain level of monitoring and procedures to ensure their reimbursement for ICU costs from April 2014. OBJECTIVE To assess whether the newly issued health policy on ICU admission criteria based on financial incentives for monitoring and procedures had any impact on clinical practices, outcomes, and ICU bed occupancy. METHODS Using a nationwide inpatient health claims database in Japan, we identified patients who were admitted to the ICU from April 2012 to March 2018. Outcomes were monitoring and procedures in the ICU, clinical outcomes, and ICU bed occupancy. The outcomes of monitoring and procedures and clinical outcomes were adjusted for patient characteristics. Interrupted time-series analyses were used to compare the trends in outcomes for two separate periods before and after the issue of the new health policy on ICU admission criteria in April 2014. RESULTS A total of 1,660,601 patients in 259 ICU-equipped hospitals were eligible. There were significant upward slope changes between the pre- and post-issue periods for all monitoring and procedures in the ICU, including invasive arterial pressure monitoring (5.62% change in trend per year; 95% CI, 4.75%-6.49%) and central venous pressure monitoring (1.22% change in trend per year; 95% CI, 0.78%-1.67%). There was no significant slope change between the pre- and post-issue periods for in-hospital mortality, but there were significant upward slope changes for complications of pneumonia (0.27% change in trend per year; 95% CI, 0.14%-0.39%) and catheter-related bloodstream infection (0.02% change in trend per year; 95% CI, 0.00%-0.14%). There were also significant upward slope changes in length of hospital stay, length of ICU stay, and hospitalization costs between the pre- and post-issue periods. There was no significant slope change between the pre- and post-issue periods for ICU bed occupancy. CONCLUSIONS The health policy on ICU admission criteria based on financial incentives for actions taken by providers was associated with increased monitoring and procedures, complications, lengths of hospital and ICU stay, and hospitalization costs without decreasing ICU bed occupancy.
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What have we learned from the first to the second wave of COVID-19 pandemic? An international survey from the ESCMID Study Group for Infection in the Elderly (ESGIE) group. Eur J Clin Microbiol Infect Dis 2021; 41:281-288. [PMID: 34775534 PMCID: PMC8590524 DOI: 10.1007/s10096-021-04377-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022]
Abstract
The purpose of this survey is to explore changes in the management of COVID-19 during the first versus the second wave, with particular emphasis on therapies, antibiotic prescriptions, and elderly care. An internet-based questionnaire survey was distributed to European Society of Clinical Microbiology and Infectious Diseases (ESCMID) members. Therapeutic approach to patients with mild-to-moderate (PiO2/FiO2 200–350) and severe (PiO2/FiO2 < 200) COVID-19, antibiotic use, and reasons for excluding patients from the intensive care unit (ICU) were investigated. A total of 463 from 21 countries participated in the study. Most representatives were infectious disease specialists (68.3%). During the second wave of pandemic, physicians abandoned the use of hydroxychloroquine, lopinavir/ritonavir, and azithromycin in favor of dexamethasone, low-molecular weight heparin (LMWH), and remdesivir in mild-to-moderate COVID-19. In critically ill patients, we detected an increased use of high-dose steroids (51%) and a decrease in tocilizumab use. The use of antibiotics at hospital admission decreased but remained high in the second wave. Age was reported to be a main consideration for exclusion of patients from ICU care by 25% of responders; a third reported that elderly were not candidates for ICU admission in their center. The decision to exclude patients from ICU care was based on the individual decision of an intensivist in 59.6% of cases. The approach of physicians to COVID-19 changed over time following evidence accumulation and guidelines. Antibiotic use at hospital admission and decision to exclude patients from ICU care remain critical aspects that should be better investigated and harmonized among clinicians.
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Jung C, Flaatten H, de Lange D, Beil M, Guidet B. The relationship between treatment limitations and pressure on intensive care units in elderly patients. Intensive Care Med 2021; 48:124-125. [PMID: 34741189 PMCID: PMC8570396 DOI: 10.1007/s00134-021-06553-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Christian Jung
- Department of Cardiology, Pulmonary Diseases and Vascular Medicine, Faculty of Medicine, Düsseldorf University Hospital, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Michael Beil
- Department of Medicine, NHS Scotland, Inverness, UK
| | - Bertrand Guidet
- Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
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Swearingen D, Boverman G, Tgavalekos K, Noren DP, Ravindranath S, Ghosh E, Xu M, Wondrely L, Thompson P, Cowden JD, Antonescu C. A Retrospective Cohort Study of Clinical Factors Associated with Transitions of Care among COVID-19 Patients. J Clin Med 2021; 10:jcm10194605. [PMID: 34640626 PMCID: PMC8509460 DOI: 10.3390/jcm10194605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 12/27/2022] Open
Abstract
Coronavirus Disease 2019 (COVID-19) is an international health crisis. In this article, we report on patient characteristics associated with care transitions of: 1) hospital admission from the emergency department (ED) and 2) escalation to the intensive care unit (ICU). Analysis of data from the electronic medical record (EMR) was performed for patients with COVID-19 seen in the ED of a large Western U.S. Health System from April to August of 2020, totaling 10,079 encounters. Of these, 5172 resulted in admission as an inpatient within 72 h. Inpatient encounters (n = 6079) were also considered for patients with positive COVID-19 test results, of which 970 resulted in a transfer to the ICU or in-hospital mortality. Laboratory results, vital signs, symptoms, and comorbidities were investigated for each of these care transitions. Different top risk factors were found, but two factors common to hospital admission and ICU transfer were respiratory rate and the need for oxygen support. Comorbidities common to both settings were cerebrovascular disease and congestive heart failure. Regarding laboratory results, the neutrophil-to-lymphocyte ratio was associated with transitions to higher levels of care, along with the ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT).
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Affiliation(s)
- Dennis Swearingen
- Department of Medical Informatics, Banner Health, Phoenix, AZ 85012, USA; (D.S.); (P.T.); (J.D.C.); (C.A.)
- Department of Biomedical Informatics, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
| | - Gregory Boverman
- Connected Care and Personal Health Department, Philips Research North America, Cambridge, MA 02141, USA; (K.T.); (D.P.N.); (S.R.); (E.G.); (M.X.); (L.W.)
- Correspondence:
| | - Kristen Tgavalekos
- Connected Care and Personal Health Department, Philips Research North America, Cambridge, MA 02141, USA; (K.T.); (D.P.N.); (S.R.); (E.G.); (M.X.); (L.W.)
| | - David P. Noren
- Connected Care and Personal Health Department, Philips Research North America, Cambridge, MA 02141, USA; (K.T.); (D.P.N.); (S.R.); (E.G.); (M.X.); (L.W.)
| | - Shreyas Ravindranath
- Connected Care and Personal Health Department, Philips Research North America, Cambridge, MA 02141, USA; (K.T.); (D.P.N.); (S.R.); (E.G.); (M.X.); (L.W.)
| | - Erina Ghosh
- Connected Care and Personal Health Department, Philips Research North America, Cambridge, MA 02141, USA; (K.T.); (D.P.N.); (S.R.); (E.G.); (M.X.); (L.W.)
| | - Minnan Xu
- Connected Care and Personal Health Department, Philips Research North America, Cambridge, MA 02141, USA; (K.T.); (D.P.N.); (S.R.); (E.G.); (M.X.); (L.W.)
| | - Lisa Wondrely
- Connected Care and Personal Health Department, Philips Research North America, Cambridge, MA 02141, USA; (K.T.); (D.P.N.); (S.R.); (E.G.); (M.X.); (L.W.)
| | - Pam Thompson
- Department of Medical Informatics, Banner Health, Phoenix, AZ 85012, USA; (D.S.); (P.T.); (J.D.C.); (C.A.)
| | - J. David Cowden
- Department of Medical Informatics, Banner Health, Phoenix, AZ 85012, USA; (D.S.); (P.T.); (J.D.C.); (C.A.)
| | - Corneliu Antonescu
- Department of Medical Informatics, Banner Health, Phoenix, AZ 85012, USA; (D.S.); (P.T.); (J.D.C.); (C.A.)
- Department of Biomedical Informatics, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
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Lombardi Y, Azoyan L, Szychowiak P, Bellamine A, Lemaitre G, Bernaux M, Daniel C, Leblanc J, Riller Q, Steichen O. External validation of prognostic scores for COVID-19: a multicenter cohort study of patients hospitalized in Greater Paris University Hospitals. Intensive Care Med 2021; 47:1426-1439. [PMID: 34585270 PMCID: PMC8478265 DOI: 10.1007/s00134-021-06524-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 12/21/2022]
Abstract
Purpose The Coronavirus disease 2019 (COVID-19) has led to an unparalleled influx of patients. Prognostic scores could help optimizing healthcare delivery, but most of them have not been comprehensively validated. We aim to externally validate existing prognostic scores for COVID-19. Methods We used “COVID-19 Evidence Alerts” (McMaster University) to retrieve high-quality prognostic scores predicting death or intensive care unit (ICU) transfer from routinely collected data. We studied their accuracy in a retrospective multicenter cohort of adult patients hospitalized for COVID-19 from January 2020 to April 2021 in the Greater Paris University Hospitals. Areas under the receiver operating characteristic curves (AUC) were computed for the prediction of the original outcome, 30-day in-hospital mortality and the composite of 30-day in-hospital mortality or ICU transfer. Results We included 14,343 consecutive patients, 2583 (18%) died and 5067 (35%) died or were transferred to the ICU. We examined 274 studies and found 32 scores meeting the inclusion criteria: 19 had a significantly lower AUC in our cohort than in previously published validation studies for the original outcome; 25 performed better to predict in-hospital mortality than the composite of in-hospital mortality or ICU transfer; 7 had an AUC > 0.75 to predict in-hospital mortality; 2 had an AUC > 0.70 to predict the composite outcome. Conclusion Seven prognostic scores were fairly accurate to predict death in hospitalized COVID-19 patients. The 4C Mortality Score and the ABCS stand out because they performed as well in our cohort and their initial validation cohort, during the first epidemic wave and subsequent waves, and in younger and older patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06524-w.
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Affiliation(s)
- Yannis Lombardi
- Faculty of Medicine, AP-HP, Sorbonne Université, Paris, France
| | - Loris Azoyan
- Faculty of Medicine, AP-HP, Sorbonne Université, Paris, France
| | - Piotr Szychowiak
- Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire de Tours, Tours, France.,Université de Tours, Tours, France
| | | | | | - Mélodie Bernaux
- Strategy and Transformation Department, AP-HP, Paris, France
| | | | - Judith Leblanc
- Institut Pierre Louis d'Épidémiologie et de Santé Publique, UMR-S 1136 , Sorbonne Université, INSERM, Paris, France.,Clinical Research Platform, Saint Antoine Hospital, AP-HP, Paris, France
| | - Quentin Riller
- Faculty of Medicine, AP-HP, Sorbonne Université, Paris, France
| | - Olivier Steichen
- Institut Pierre Louis d'Épidémiologie et de Santé Publique, UMR-S 1136 , Sorbonne Université, INSERM, Paris, France. .,Internal Medicine Department, Tenon Hospital, AP-HP, Sorbonne Université, Paris, France. .,Service de Médecine Interne, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.
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Courjon J, Contenti J, Demonchy E, Levraut J, Barbry P, Rios G, Dellamonica J, Chirio D, Bonnefoy C, Giordanengo V, Carles M. COVID-19 patients age, comorbidity profiles and clinical presentation related to the SARS-CoV-2 UK-variant spread in the Southeast of France. Sci Rep 2021; 11:18456. [PMID: 34531412 PMCID: PMC8446095 DOI: 10.1038/s41598-021-95067-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/20/2021] [Indexed: 12/13/2022] Open
Abstract
The variant 20I/501Y.V1, associated to a higher risk of transmissibility, emerged in Nice city (Southeast of France, French Riviera) during January 2021. The pandemic has resumed late December 2020 in this area. A high incidence rate together with a fast turn-over of the main circulating variants, provided us the opportunity to analyze modifications in clinical profile and outcome traits. We performed an observational study in the University hospital of Nice from December 2020 to February 2021. We analyzed data of sequencing of SARS-CoV-2 from the sewage collector and PCR screening from all positive samples at the hospital. Then, we described the characteristics of all COVID-19 patients admitted in the emergency department (ED) (n = 1247) and those hospitalized in the infectious diseases ward or ICU (n = 232). The UK-variant was absent in this area in December, then increasingly spread in January representing 59% of the PCR screening performed mid-February. The rate of patients over 65 years admitted to the ED decreased from 63 to 50% (p = 0.001). The mean age of hospitalized patients in the infectious diseases ward decreased from 70.7 to 59.2 (p < 0.001) while the proportion of patients without comorbidity increased from 16 to 42% (p = 0.007). Spread of the UK-variant in the Southeast of France affects younger and healthier patients.
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Affiliation(s)
- Johan Courjon
- Infectious Diseases Department, Université Côte d'Azur, CHU de Nice, Hôpital Archet 1 Infectiologie 151 route de St Antoine de Ginestière, 06200, Nice, France. .,Université Côte d'Azur, Inserm, U1065, C3M, Nice, France.
| | - Julie Contenti
- Université Côte d'Azur, Inserm, U1065, C3M, Nice, France.,Emergency Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - Elisa Demonchy
- Infectious Diseases Department, Université Côte d'Azur, CHU de Nice, Hôpital Archet 1 Infectiologie 151 route de St Antoine de Ginestière, 06200, Nice, France
| | - Jacques Levraut
- Emergency Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - Pascal Barbry
- Institut de Pharmacologie Moleculaire et Cellulaire, UMR7275 CNRS/UNS, Valbonne, France
| | - Géraldine Rios
- Institut de Pharmacologie Moleculaire et Cellulaire, UMR7275 CNRS/UNS, Valbonne, France
| | - Jean Dellamonica
- Medical Intensive Care Unit Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - David Chirio
- Infectious Diseases Department, Université Côte d'Azur, CHU de Nice, Hôpital Archet 1 Infectiologie 151 route de St Antoine de Ginestière, 06200, Nice, France
| | | | - Valérie Giordanengo
- Université Côte d'Azur, Inserm, U1065, C3M, Nice, France.,Virology Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - Michel Carles
- Infectious Diseases Department, Université Côte d'Azur, CHU de Nice, Hôpital Archet 1 Infectiologie 151 route de St Antoine de Ginestière, 06200, Nice, France.,Université Côte d'Azur, Inserm, U1065, C3M, Nice, France
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41
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Dichter JR, Devereaux AV, Sprung CL, Mukherjee V, Persoff J, Baum KD, Ornoff D, Uppal A, Hossain T, Henry KN, Ghazipura M, Bowden KR, Feldman HJ, Hamele MT, Burry LD, Martland AMO, Huffines M, Tosh PK, Downar J, Hick JL, Christian MD, Maves RC. Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care. Chest 2021; 161:429-447. [PMID: 34499878 PMCID: PMC8420082 DOI: 10.1016/j.chest.2021.08.072] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/05/2021] [Accepted: 08/19/2021] [Indexed: 01/25/2023] Open
Abstract
Background After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. Research Question A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. Study Design and Methods TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, “gray” evidence from lay media sources, and anecdotal experiential evidence. Results Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. Interpretation A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.
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Affiliation(s)
| | | | | | | | | | | | | | - Amit Uppal
- Grossman School of Medicine, New York University, New York, NY
| | - Tanzib Hossain
- Grossman School of Medicine, New York University, New York, NY
| | | | - Marya Ghazipura
- Grossman School of Medicine, New York University, New York, NY
| | | | - Henry J Feldman
- Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Cambridge, MA
| | - Mitchell T Hamele
- Uniformed Services University, Bethesda, MD; Tripler Army Medical Center, Honolulu, HI
| | | | | | | | | | | | - John L Hick
- University of Minnesota, Minneapolis, MN; Hennepin Health Care, Minneapolis, MN
| | - Michael D Christian
- Research & Clinical Effectiveness Lead/HEMS Doctor, London's Air Ambulance, Bart's NHS Health Trust, London, England
| | - Ryan C Maves
- Uniformed Services University, Bethesda, MD; Wake Forest School of Medicine, Winston-Salem, NC
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Rubio O, Cabré L, Estella A, Ferrer R. Reply to "Considerations on ICU triage ethics during the COVID-19 pandemic". Med Intensiva 2021; 45:382. [PMID: 34294238 PMCID: PMC8092810 DOI: 10.1016/j.medine.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/05/2020] [Indexed: 11/17/2022]
Affiliation(s)
- O Rubio
- Hospital Sant Joan de Déu de Manresa, Manresa, Spain.
| | - L Cabré
- Hospital de Barcelona, Barcelona, Spain
| | - A Estella
- Hospital de Jerez de la Frontera, Jerez de la Frontera, Spain
| | - R Ferrer
- Hospital Universitario de Valle Hebrón, Barcelona, Spain
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43
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Monti G, Leggieri C, Fominskiy E, Scandroglio AM, Colombo S, Tozzi M, Moizo E, Mucci M, Crivellari M, Pieri M, Guzzo F, Piemontese S, De Lorenzo R, Da Prat V, Fedrizzi M, Faustini C, Di Piazza M, Conte F, Lembo R, Esposito A, Dagna L, Landoni G, Zangrillo A. Two-months quality of life of COVID-19 invasively ventilated survivors; an Italian single-center study. Acta Anaesthesiol Scand 2021; 65:912-920. [PMID: 33655487 PMCID: PMC8014684 DOI: 10.1111/aas.13812] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 01/11/2023]
Abstract
Background COVID‐19 disease can lead to severe functional impairments after discharge. We assessed the quality of life of invasively ventilated COVID‐19 ARDS survivors. Methods We carried out a prospective follow‐up study of the patients admitted to the Intensive Care Units (ICUs) of a teaching hospital. Patients affected by COVID‐19 ARDS who required invasive ventilation and were successfully discharged home were assessed through the telephone administration of validated tests. We explored survival, functional outcomes, return to work, quality of life, cognitive and psychological sequelae. The main variables of interest were the following: demographics, severity scores, laboratory values, comorbidities, schooling, working status, treatments received during ICU stay, complications, and psychological, cognitive, functional outcomes. Results Out of 116 consecutive invasively ventilated patients, overall survival was 65/116 (56%) with no death occurring after hospital discharge. Forty‐two patients were already discharged home with a median follow‐up time of 61 (51‐71) days after ICU discharge and 39 of them accepted to be interviewed. Only one patient (1/39) experienced cognitive decline. The vast majority of patients reported no difficulty in walking (32/35:82%), self‐care (33/39:85%), and usual activities (30/39:78%). All patients were either malnourished (15/39:38%) or at risk for malnutrition (24/39:62%). Exertional dyspnea was present in 20/39 (51%) patients. 19/39 (49%) reported alterations in senses of smell and/or taste either before or after hospitalization. Conclusions Invasively ventilated COVID‐19 ARDS survivors have an overall good recovery at a 2‐months follow‐up which is better than what was previously reported in non‐COVID‐19 ARDS patients.
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Affiliation(s)
- Giacomo Monti
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Carlo Leggieri
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Evgeny Fominskiy
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Anna Mara Scandroglio
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Sergio Colombo
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Margherita Tozzi
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Elena Moizo
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Milena Mucci
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Martina Crivellari
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Marina Pieri
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Francesca Guzzo
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Simona Piemontese
- IRCCS San Raffaele Scientific Institute, Hematology and Bone Marrow Transplant Unit Milan Italy
| | - Rebecca De Lorenzo
- Department of Internal Medicine IRCCS San Raffaele Scientific Institute Milan Italy
| | - Valentina Da Prat
- General Medicine and Advanced Care Unit IRCCS San Raffaele Scientific Institute Milan Italy
| | - Monica Fedrizzi
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Carolina Faustini
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Martina Di Piazza
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Francesca Conte
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Rosalba Lembo
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Antonio Esposito
- IRCCS San Raffaele Scientific InstituteClinical and Experimental Radiology UnitExperimental Imaging Centre Milan Italy
| | - Lorenzo Dagna
- IRCCS San Raffaele Scientific Institute, Medicine and Clinical Immunology Milan Italy
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Alberto Zangrillo
- Vita‐Salute University San Raffaele, Milano, ItaliaAnesthesia and Intensive Care Milan Italy
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Performance of Crisis Standards of Care Guidelines in a Cohort of Critically Ill COVID-19 Patients in the United States. CELL REPORTS MEDICINE 2021. [PMID: 34337554 PMCID: PMC8316067 DOI: 10.1016/j.xcrm.2021.100376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities. Crisis standards of care (CSC) guidelines have poor prediction of 28-day mortality Consideration of comorbidities modestly improves guideline performance Simulation of clinical decision-making shows frequent ties in priority scores Using comorbidities in CSC has the potential to exacerbate racial inequities
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Ottenhoff MC, Ramos LA, Potters W, Janssen MLF, Hubers D, Hu S, Fridgeirsson EA, Piña-Fuentes D, Thomas R, van der Horst ICC, Herff C, Kubben P, Elbers PWG, Marquering HA, Welling M, Simsek S, de Kruif MD, Dormans T, Fleuren LM, Schinkel M, Noordzij PG, van den Bergh JP, Wyers CE, Buis DTB, Wiersinga WJ, van den Hout EHC, Reidinga AC, Rusch D, Sigaloff KCE, Douma RA, de Haan L, Gritters van den Oever NC, Rennenberg RJMW, van Wingen GA, Aries MJH, Beudel M. Predicting mortality of individual patients with COVID-19: a multicentre Dutch cohort. BMJ Open 2021; 11:e047347. [PMID: 34281922 PMCID: PMC8290951 DOI: 10.1136/bmjopen-2020-047347] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/16/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Develop and validate models that predict mortality of patients diagnosed with COVID-19 admitted to the hospital. DESIGN Retrospective cohort study. SETTING A multicentre cohort across 10 Dutch hospitals including patients from 27 February to 8 June 2020. PARTICIPANTS SARS-CoV-2 positive patients (age ≥18) admitted to the hospital. MAIN OUTCOME MEASURES 21-day all-cause mortality evaluated by the area under the receiver operator curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value. The predictive value of age was explored by comparison with age-based rules used in practice and by excluding age from the analysis. RESULTS 2273 patients were included, of whom 516 had died or discharged to palliative care within 21 days after admission. Five feature sets, including premorbid, clinical presentation and laboratory and radiology values, were derived from 80 features. Additionally, an Analysis of Variance (ANOVA)-based data-driven feature selection selected the 10 features with the highest F values: age, number of home medications, urea nitrogen, lactate dehydrogenase, albumin, oxygen saturation (%), oxygen saturation is measured on room air, oxygen saturation is measured on oxygen therapy, blood gas pH and history of chronic cardiac disease. A linear logistic regression and non-linear tree-based gradient boosting algorithm fitted the data with an AUC of 0.81 (95% CI 0.77 to 0.85) and 0.82 (0.79 to 0.85), respectively, using the 10 selected features. Both models outperformed age-based decision rules used in practice (AUC of 0.69, 0.65 to 0.74 for age >70). Furthermore, performance remained stable when excluding age as predictor (AUC of 0.78, 0.75 to 0.81). CONCLUSION Both models showed good performance and had better test characteristics than age-based decision rules, using 10 admission features readily available in Dutch hospitals. The models hold promise to aid decision-making during a hospital bed shortage.
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Affiliation(s)
- Maarten C Ottenhoff
- Department of Neurosurgery, Maastricht University, Maastricht, The Netherlands
| | - Lucas A Ramos
- Department of Biomedical Engineering and Physics/Department of Epidemiology & Data Science, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Wouter Potters
- Department of Neurology, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Marcus L F Janssen
- Department of Clinical Neurophysiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Deborah Hubers
- Department of Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Shi Hu
- Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Egill A Fridgeirsson
- Department of Psychiatry, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Dan Piña-Fuentes
- Department of Neurology, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Rajat Thomas
- Department of Psychiatry, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Christian Herff
- Department of Neurosurgery, Maastricht University, Maastricht, The Netherlands
| | - Pieter Kubben
- Department of Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics/Department of Epidemiology & Data Science, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Max Welling
- Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Suat Simsek
- Department of Internal Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
- Department of Internal Medicine, Section of Endocrinology, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
| | - Martijn D de Kruif
- Department of Pulmonary Medicine, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Tom Dormans
- Vascular Medicine, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, The Netherlands
| | - Michiel Schinkel
- Center for Experimental and Molecular Medicine (C.E.M.M.), Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Peter G Noordzij
- Department of Anesthesiology and Intensive Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Caroline E Wyers
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
| | - David T B Buis
- Department of Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
- Center for Experimental and Molecular Medicine (C.E.M.M.), Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ella H C van den Hout
- Department of Internal Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Auke C Reidinga
- Department of Intensive Care, Martini Ziekenhuis, Groningen, The Netherlands
| | - Daisy Rusch
- Research, Martini Ziekenhuis, Groningen, The Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Renee A Douma
- Department of Internal Medicine, Flevoziekenhuis, Almere, Flevoland, The Netherlands
| | - Lianne de Haan
- Department of Internal Medicine, Flevoziekenhuis, Almere, Flevoland, The Netherlands
| | | | - Roger J M W Rennenberg
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Guido A van Wingen
- Department of Psychiatry, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel J H Aries
- Department of Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Martijn Beudel
- Department of Neurology, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
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Serrano R, Corbella X, Rello J. Management of hypoxemia in SARS-CoV-2 infection: Lessons learned from one year of experience, with a special focus on silent hypoxemia. JOURNAL OF INTENSIVE MEDICINE 2021; 1:26-30. [PMID: 36943810 PMCID: PMC7939974 DOI: 10.1016/j.jointm.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/29/2021] [Accepted: 02/18/2021] [Indexed: 12/21/2022]
Abstract
Silent hypoxemia is common in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this article, the possible pathophysiological mechanisms underlying respiratory symptoms have been reviewed, and the presence of hypoxemia without hypoxia is also discussed. The experience we have gained since the start of the Coronavirus disease 19 (COVID-19) pandemic has changed our point of view about which patients with respiratory involvement should be admitted to the intensive care unit/high-dependency unit for mechanical ventilation and monitoring. In patients with clinically well-tolerated mild to moderate hypoxemia (silent hypoxemia), regardless of the extent of pulmonary opacities found in radiological studies, the administration of supplemental oxygen therapy may increase the risk of endothelial damage. The risk of sudden respiratory arrest during emergency intubation, which could expose healthcare workers to infection, should be considered along with the risks of premature intubation. Criteria for intubation need to be revisited based on updated evidence showing that many patients with severe hypoxemia do not show increased work of breathing. This has implications in patient management and may explain in part reports of broad differences in outcomes among intubated patients.
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Affiliation(s)
- Ricardo Serrano
- Critical Care Department. Hospital de Hellín. Gerencia Atención Integrada de Hellín, Albacete 02400, Spain
| | - Xavier Corbella
- Interna Medicine Department, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona 08907, Spain
- School of Medicine, Universitat Internacional de Catalunya, Barcelona 08017, Spain
| | - Jordi Rello
- Vall d'Hebron Institute of Research, Barcelona 08035, Spain
- Research in Critical Care, CHU Caremeau, Nîmes 30900, France
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
- Corresponding author: Jordi Rello, Vall d'Hebron Institute of Research, P. Vall d'Hebron 129. AMI-14, Barcelona 08035, Spain.
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Jones-Bonofiglio K, Nortjé N, Webster L, Garros D. A Practical Approach to Hospital Visitation During a Pandemic: Responding With Compassion to Unjustified Restrictions. Am J Crit Care 2021; 30:302-311. [PMID: 33870412 DOI: 10.4037/ajcc2021611] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
During the COVID-19 pandemic, evidence-based resources have been sought to support decision-making and strategically inform hospitals' policies, procedures, and practices. While greatly emphasizing protection, most guiding documents have neglected to support and protect the psychosocial needs of frontline health care workers and patients and their families during provision of palliative and end-of-life care. Consequently, the stage has been set for increased anxiety, moral distress, and moral injury and extreme moral hazard. A family-centered approach to care has been unilaterally relinquished to a secondary and nonessential role during the current crisis. This phenomenon violates a foundational public health principle, namely, to apply the least restrictive means to achieve good for the many. Instead, there has been widespread adoption of utilitarian and paternalistic approaches. In many cases the foundational principles of palliative care have also been neglected. No circumstance, even a global public health emergency, should ever cause health care providers to deny their ethical obligations and human commitment to compassion. The lack of responsive protocols for family visitation, particularly at the end of life, is an important gap in the current recommendations for pandemic triage and contingency planning. A stepwise approach to hospital visitation using a tiered, standardized process for responding to emerging clinical circumstances and individual patients' needs should be considered, following the principle of proportionality. A contingency plan, based on epidemiological data, is the best strategy to refocus health care ethics in practice now and for the future.
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Affiliation(s)
- Kristen Jones-Bonofiglio
- Kristen Jones-Bonofiglio is an assistant professor, School of Nursing, and director of the Centre for Health Care Ethics, Lakehead University, in Thunder Bay, Ontario, Canada
| | - Nico Nortjé
- Nico Nortjé is an assistant professor, critical care and respiratory care, and a clinical ethicist, Section of Integrated Ethics in Cancer Care, The University of Texas, MD Anderson Cancer Center, Houston; a research affiliate, Centre for Health Care Ethics, Lakehead University, Thunder Bay, Ontario, Canada; and professor extraordinaire, Department of Dietetics and Nutrition, University of the Western Cape, Bellville, South Africa
| | - Laura Webster
- Laura Webster is director of the bioethics program, Virginia Mason Medical Center, Seattle, Washington, and affiliate faculty, Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Daniel Garros
- Daniel Garros is a clinical professor, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, and a member of the Ethics Committee and senior attending physician in the pediatric intensive care unit, Stollery Children’s Hospital, Edmonton, Alberta, Canada
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Armiñanzas C, Arnaiz de Las Revillas F, Gutiérrez Cuadra M, Arnaiz A, Fernández Sampedro M, González-Rico C, Ferrer D, Mora V, Suberviola B, Latorre M, Calvo J, Olmos JM, Cifrián JM, Fariñas MC. Usefulness of the COVID-GRAM and CURB-65 scores for predicting severity in patients with COVID-19. Int J Infect Dis 2021; 108:282-288. [PMID: 34044145 PMCID: PMC8142713 DOI: 10.1016/j.ijid.2021.05.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/23/2022] Open
Abstract
AIM The aim of this study was to determine the usefulness of COVID-GRAM and CURB-65 scores as predictors of the severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Caucasian patients. METHODS This was a retrospective observational study including all adults with SARS-CoV-2 infection admitted to Hospital Universitario Marqués de Valdecilla from February to May 2020. Patients were stratified according to COVID-GRAM and CURB-65 scores as being at low-medium or high risk of critical illness. Univariate analysis, multivariate logistic regression models, receiver operating characteristic curve, and area under the curve (AUC) were calculated. RESULTS A total of 523 patients were included (51.8% male, 48.2% female; mean age 65.63 years (standard deviation 17.89 years)), of whom 110 (21%) presented a critical illness (intensive care unit admission 10.3%, 30-day mortality 13.8%). According to the COVID-GRAM score, 122 (23.33%) patients were classified as high risk; 197 (37.7%) presented a CURB-65 score ≥2. A significantly greater proportion of patients with critical illness had a high COVID-GRAM score (64.5% vs 30.5%; P < 0.001). The COVID-GRAM score emerged as an independent predictor of critical illness (odds ratio 9.40, 95% confidence interval 5.51-16.04; P < 0.001), with an AUC of 0.779. A high COVID-GRAM score showed an AUC of 0.88 for the prediction of 30-day mortality, while a CURB-65 ≥2 showed an AUC of 0.83. CONCLUSIONS The COVID-GRAM score may be a useful tool for evaluating the risk of critical illness in Caucasian patients with SARS-CoV-2 infection. The CURB-65 score could be considered as an alternative.
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Affiliation(s)
- Carlos Armiñanzas
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
| | - Francisco Arnaiz de Las Revillas
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
| | - Manuel Gutiérrez Cuadra
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
| | - Ana Arnaiz
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
| | - Marta Fernández Sampedro
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
| | - Claudia González-Rico
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
| | - Diego Ferrer
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - Víctor Mora
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - Borja Suberviola
- Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - Maite Latorre
- Service of Internal Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - Jorge Calvo
- Service of Microbiology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
| | - José Manuel Olmos
- Service of Internal Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - José Manuel Cifrián
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - María Carmen Fariñas
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain.
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Operationalizing Ethical Guidance for Ventilator Allocation in Minnesota: Saving the Most Lives or Exacerbating Health Disparities? Crit Care Explor 2021; 3:e0455. [PMID: 34136826 PMCID: PMC8202637 DOI: 10.1097/cce.0000000000000455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: A statewide working group in Minnesota created a ventilator allocation scoring system in anticipation of functioning under a Crisis Standards of Care declaration. The scoring system was intended for patients with and without coronavirus disease 2019. There was disagreement about whether the scoring system might exacerbate health disparities and about whether the score should include age. We measured the relationship of ventilator scores to in-hospital and 3-month mortality. We analyzed our findings in the context of ethical and legal guidance for the triage of scarce resources. DESIGN: Retrospective cohort study. SETTING: Multihospital within a single healthcare system. PATIENTS: Five-hundred four patients emergently intubated and admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Ventilator Allocation Score was positively associated with higher mortality (p < 0.0001). The 3-month mortality rate for patients with a score of 6 or higher was 96% (42/44 patients). Age was positively associated with mortality. The 3-month mortality rate for patients 80 and older with scores of 4 or greater was 93% (40/43 patients). Of patients assigned a score of 5, those with end stage renal disease had lower mortality than patients without end stage renal disease although the difference did not achieve statistical significance (n = 27; 25% vs 58%; p = 0.2). CONCLUSIONS: The Ventilator Allocation Score can accurately identify patients with high rates of short-term mortality. However, these high mortality patients only represent 27% of all the patients who died, limiting the utility of the score for allocation of scarce resources. The score may unfairly prioritize older patients and inadvertently exacerbate racial health disparities through the inclusion of specific comorbidities such as end stage renal disease. Triage frameworks that include age should be considered. Purposeful efforts must be taken to ensure that triage protocols do not perpetuate or exacerbate prevailing inequities. Further work on the allocation of scarce resources in critical care settings would benefit from consensus on the primary ethical objective.
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The Lived Experience of ICU Clinicians During the Coronavirus Disease 2019 Outbreak: A Qualitative Study. Crit Care Med 2021; 49:e585-e597. [PMID: 33591018 DOI: 10.1097/ccm.0000000000004939] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES During the coronavirus disease 2019 pandemic, frontline healthcare professionals were asked to reorganize the provision of critical care in unprecedented ways. Our aim was to gain insight into the lived experience of clinicians who worked in ICUs during the surge. DESIGN Qualitative study using semistructured, in-depth interviews. SETTING Clinicians who worked in three ICUs in Paris (France) during the peak of the pandemic (April and May 2020). PARTICIPANTS Twenty-seven ICU clinicians (12 physicians, 11 nurses, three nursing assistants, and one respiratory therapist). MEASUREMENTS AND MAIN RESULTS Interviews were audio recorded and analyzed using thematic analysis. Six themes emerged: coping with initial disorganization and creating new routines, the intensification of professional relationships and the development of unexpected collaborations, losing one's reference points and recreating meaningful interactions with patients, working under new constraints and developing novel interactions with family members, compensating for the absence of family members and rituals at the end of life, and the full engagement of ICU clinicians during the coronavirus disease 2019 crisis. CONCLUSIONS Among ICU clinicians, there was a sense of total professional engagement during the surge. Caring for critically ill coronavirus disease 2019 patients was fraught with challenges and generated a strong feeling of responsibility, as clinicians felt they had to compensate for the absence of family members. Rethinking policies about family visits and safeguarding positive relationships among colleagues are two important priorities for future healthcare crises.
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