International comparisons of intensive care: informing outcomes and improving standards

The impact of clearly defined debriefing practices on nurses working within an adult intensive care: A systematic review

OBJECTIVES

To critically analyse and synthesise the literature describing the relationship between a debriefing intervention and wellbeing in the distinct population of registered nurses working in the adult Intensive Care Unit (ICU).

METHODS

The JBI literature review methodology was used to analyse primary research exploring a clearly defined debriefing process with an aim to improving wellbeing in the setting and population of ICU nurses. A comprehensive search of primary research published between 1st January 2004 and 9th May 2024 was conducted. A systematic search was conducted across multiple scholarly databases: APA PsycInfo, CINAHL Complete, PubMed and Embase. Google Scholar and reference lists were also searched. Data from the included studies were extracted by one author, and then checked and verified by a second author. Included studies are summarised according to study details, debriefing characteristics and reported wellbeing results. Studies were appraised using the Mixed Methods Appraisal Tool.

RESULTS

The search yielded 732 articles, with 12 articles screened in full-text format. Three primary research studies met the inclusion criteria. All included studies utilised a mixed methods design, there was significant heterogeneity between logistical components of the debriefing intervention as well as study instruments and reporting.

CONCLUSION

This systematic review illustrates a paucity of available research on the specificity of debriefing practices and the potential relationship to wellbeing in the ICU nursing population.

IMPLICATIONS FOR CLINICAL PRACTICE

Further rigorous research is required surrounding the implementation and effectiveness of debriefing in the unique population of ICU nurses.

Acute Kidney Injury in Latin America

Acute kidney injury (AKI) is a major global health issue with significant morbidity and mortality, particularly in low- and middle-income regions like Latin America. AKI prevalence varies across Latin America, with higher rates in rural and underserved areas. Key risk factors include socioeconomic disparities, comorbid conditions such as diabetes and hypertension, and environmental hazards. Infections, especially tropical diseases, and exposure to nephrotoxins, including herbal remedies, are common causes of AKI. Management of AKI faces significant hurdles because of limited access to diagnostic tools, variability in clinical practices, and a shortage of trained health care professionals. The availability of dialysis and renal replacement therapies is often constrained by economic and infrastructural limitations. Public health initiatives focusing on prevention, screening, and early detection are critical to mitigate the impact of AKI. Research in AKI across Latin America is hampered by data gaps and limited funding. Multicenter collaborations and the development of region-specific guidelines are essential to improving outcomes. Addressing these challenges will help reduce the burden of AKI and improve health care systems across the region. This review examines the unique epidemiology, risk factors, and health care challenges surrounding AKI in the region.

Acute decompensated pulmonary hypertension outcomes in pulmonary arterial hypertension patients: systematic review and meta-analysis of proportions

BACKGROUND

Acute decompensated pulmonary arterial hypertension (ADPH) is characterized by right heart failure due to elevated afterload and inadequate cardiac output, and it presents a significant mortality risk. Understanding mortality proportions and the impact of life-sustaining therapies is crucial for informing clinical practice and patient prognosis.

OBJECTIVES

To assess mortality proportions in ADPH across different clinical settings and to assess how they vary depending on the type of life-sustaining interventions used.

METHODS

A systematic review and meta-analysis of proportions were conducted, examining mortality in ADPH focusing on three primary outcomes: ICU mortality, hospital mortality, and hospital mortality in patients requiring extracorporeal membrane oxygenation (ECMO). Common and random-effects meta-analyses were performed to calculate pooled mortality proportions with 95% confidence intervals (CI95%). Temporal trends were analyzed using meta-regression.

RESULTS

Twenty-five observational studies conducted between 2003 and 2023, involving 1,249 ADPH patients, were included. The random-effect analysis revealed an ICU pooled mortality proportion of 29% (CI95% 25-34, I2=40%, p=0.12) and a pooled hospital mortality proportion of 38% (CI95% 31-47, I2=70%, p<0.01). Pooled mortality proportion for patients on ECMO was 45% (CI95% 38-52, I2=0%, p=0.96). Patients receiving inotropes or vasopressors had pooled mortality proportion of 56% (CI95% 44-68, I2=42%, p=0.18) and 57% (CI95% 48-65, I2=57%, p=0.02), respectively. Meta-regression analysis revealed no significant trend in hospital mortality over the span of twenty years.

CONCLUSIONS

Variation in ADPH mortality across hospital settings and life-sustaining therapies underscores the complexity of managing ADPH. These findings inform clinical practice and support prognostic discussions with patients and families.

Association Between Inability to Stand at ICU Discharge and Readmission: A Historical Cohort Study

OBJECTIVES

The aim of this study was to determine if being unable to stand at ICU discharge was associated with an increased probability of ICU readmission.

DESIGN

A multicenter retrospective cohort study was conducted using the Toronto Intensive Care Observational Registry (iCORE) project.

SETTING

Nine tertiary academic ICUs in Toronto, Canada, affiliated with the University of Toronto.

PATIENTS

All patients admitted to ICUs participating in iCORE from September 2014 to January 2020 were included. Patients had to be mechanically ventilated for more than 4 hours to be included in iCORE. Exclusion criteria were death during the initial ICU stay, transfer to another institution not included in iCORE at ICU discharge, and a short ICU stay defined as less than 2 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main exposure in this study was the inability of the patient to stand at ICU discharge, documented daily in the database within the ICU Mobility Scale. The primary outcome of this study was readmission to the ICU. After adjusting for potential confounders, being unable to stand at ICU discharge was associated with increased odds of readmission (odds ratio, 1.85; 95% CI, 1.31-2.62; p < 0.001).

CONCLUSIONS

In patients with an ICU stay of 2 days or more, being unable to stand at ICU discharge is associated with increased odds of readmission to the ICU.

INhaled Sedation versus Propofol in REspiratory failure in the Intensive Care Unit (INSPiRE-ICU1): protocol for a randomised, controlled trial

INTRODUCTION

Sedation in mechanically ventilated adults in the intensive care unit (ICU) is commonly achieved with intravenous infusions of propofol, dexmedetomidine or benzodiazepines. Significant limitations associated with each can impact their usage. Inhaled isoflurane has potential benefit for ICU sedation due to its safety record, sedation profile, lack of metabolism and accumulation, and fast wake-up time. Administration in the ICU has historically been restricted by the lack of a safe and effective delivery system for the ICU. The Sedaconda Anaesthetic Conserving Device-S (Sedaconda ACD-S) has enabled the delivery of inhaled volatile anaesthetics for sedation with standard ICU ventilators, but it has not yet been rigorously evaluated in the USA. We aim to evaluate the efficacy and safety of inhaled isoflurane delivered via the Sedaconda ACD-S compared with intravenous propofol for sedation of mechanically ventilated ICU adults in USA hospitals.

METHODS AND ANALYSIS

INhaled Sedation versus Propofol in REspiratory failure in the ICU (INSPiRE-ICU1) is a phase 3, multicentre, randomised, controlled, open-label, assessor-blinded trial that aims to enrol 235 critically ill adults in 14 hospitals across the USA. Eligible patients are randomised in a 1.5:1 ratio for a treatment duration of up to 48 (±6) hours or extubation, whichever occurs first, with primary follow-up period of 30 days and additional follow-up to 6 months. Primary outcome is percentage of time at target sedation range. Key secondary outcomes include use of opioids during treatment, spontaneous breathing efforts during treatment, wake-up time at end of treatment and cognitive recovery after treatment.

ETHICS AND DISSEMINATION

Trial protocol has been approved by US Food and Drug Administration (FDA) and central (Advarra SSU00208265) or local institutional review boards ((IRB), Cleveland Clinic IRB FWA 00005367, Tufts HS IRB 20221969, Houston Methodist IRB PRO00035247, Mayo Clinic IRB Mod22-001084-08, University of Chicago IRB21-1917-AM011 and Intermountain IRB 033175). Results will be presented at scientific conferences, submitted for publication, and provided to the FDA.

TRIAL REGISTRATION NUMBER

NCT05312385.

Limitations of life-sustaining therapies in South Africa

PURPOSE

Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA).

MATERIALS AND METHODS

This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world.

RESULTS

LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered.

CONCLUSIONS

Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.

Predictors of Severity of Influenza-Related Hospitalizations: Results From the Global Influenza Hospital Surveillance Network (GIHSN)

BACKGROUND

The Global Influenza Hospital Surveillance Network (GIHSN) has since 2012 provided patient-level data on severe influenza-like-illnesses from >100 participating clinical sites worldwide based on a core protocol and consistent case definitions.

METHODS

We used multivariable logistic regression to assess the risk of intensive care unit admission, mechanical ventilation, and in-hospital death among hospitalized patients with influenza and explored the role of patient-level covariates and country income level.

RESULTS

The data set included 73 121 patients hospitalized with respiratory illness in 22 countries, including 15 660 with laboratory-confirmed influenza. After adjusting for patient-level covariates we found a 7-fold increase in the risk of influenza-related intensive care unit admission in lower middle-income countries (LMICs), compared with high-income countries (P = .01). The risk of mechanical ventilation and in-hospital death also increased by 4-fold in LMICs, though these differences were not statistically significant. We also find that influenza mortality increased significantly with older age and number of comorbid conditions. Across all severity outcomes studied and after controlling for patient characteristics, infection with influenza A/H1N1pdm09 was more severe than with A/H3N2.

CONCLUSIONS

Our study provides new information on influenza severity in underresourced populations, particularly those in LMICs.

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

OBJECTIVES

Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant.

DESIGN

Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722).

SETTING

One hundred-fifty-three ICUs in 13 countries.

PATIENTS

Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007).

CONCLUSIONS

Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus

The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.

International variation in ethics and contract approval processes for a low-risk observational study of mechanical ventilation discontinuation practices

OBJECTIVES

To describe international variation in ethics and contract processes, identify predictors of approval times, and reasons for nonparticipation in an international observational study of ventilation discontinuation practices.

STUDY DESIGN AND SETTING

A nested cross-sectional survey of research personnel at 111 participating sites (representing 142 intensive care units [ICUs]) from six geographic regions (Canada, India, the United Kingdom, Europe, Australia/New Zealand, and the United States).

RESULTS

We analyzed responses from 80 sites (72.1% response rate). A single local or central approval was required at 34/80 (42.5%) and 23/80 (28.75%), respectively. Of those requiring central ethics approval, 20/23 (87.0%) sites required an additional approval. Sites with central vs. other ethics approval processes had significantly longer times to ethics approval (176 vs. 42 days; P < 0.0001). The median time to contract execution was 140 days (range: 11-1,215) with sites in India and the United States having the shortest and longest times to contract execution, respectively. We did not identify independent predictors of approval times. Of 190 sites that initially agreed to participate, 78 (41%) sites (89 ICUs) were ultimately unable to participate.

CONCLUSION

International ethics and contract approval times were lengthy and highly variable. Central ethics review processes significantly increased approval times.

Healthcare System Impact on Deceased Organ Donation and Transplantation: A Comparison Between the Top 10 Organ Donor Countries With 4 Countries in Southeast Asia

The need for organ donation is constantly increasing. Some countries have made improvements, while others, such as countries in Southeast Asia (SEA), have some of the lowest rates of deceased donors (pmp). This review aims to compare 14 countries with regards to many variables related to healthcare systems. Countries leading in deceased organ donation spend more on health and education, which is associated with increased potential for deceased organ donation. Out-of-pocket expenditure, is also associated with a decrease in deceased organ donation. Countries in SEA are lacking in healthcare resources such as workforce and materials, which are both necessary for a successful transplant program. Most countries in SEA have an excellent foundation for successful organ donation systems, including proper legislation, government support, and brain death laws along with an overall acceptance of brain death diagnosis. Priorities should include improving coordination, donor identification, and healthcare worker education. Countries in SEA have a lot of potential to increase deceased organ donation, especially by investing in healthcare and education. There is no one size fits all for organ donation programs and countries in SEA should focus on their strengths and take cultural differences into consideration when planning interventions.

The Caloric Necessities of Critical Care Patients During the First Week of Admission

INTRODUCTION

 The nutritional needs of critically ill patients have been the subject of intense controversy. In accordance with international guidelines, it is advocated to optimize a nutritional intake based on the following recommendation: 25-30 kcal/kg body weight per day. However, there still are authors who recommend permissive underfeeding in the first week of hospitalization. Nevertheless, energy expenditure (EE) and necessity are influenced by the catabolic phase of critical illness, which may vary over time on a patient and from patient to patient.

OBJECTIVE

The objective of this study is to assess if the energy needs of critically ill patients admitted in our intensive care unit (ICU) in the first week of hospitalization are in line with those recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) international guidelines.

METHODS

A prospective cross-sectional study was carried out from September to December 2019. The energy needs were evaluated by indirect calorimetry and by the Harris-Benedict equation. Stress variables were evaluated, namely, the type of pathology, hemodynamic support, sedation, temperature, sequential organ failure assessment (SOFA) score, and state at discharge.

RESULTS

Forty-six patients were included in this study, with an average energy expenditure by indirect calorimetry of 19.22 ± 4.67 kcal/kg/day. The energy expenditure was less than 20 kcal/kg/day in 63% of the measurements. The concordance rate did not show the relationship between the Harris-Benedict equation and the values of indirect calorimetry. Stress variables were analyzed, with the SOFA score as the only variable with values close to statistical significance.

CONCLUSION

In our ICU, the energy needs of critically ill patients in the first week of hospitalization are lower than the intake recommended by the guidelines.

Macroeconomic Effects of COVID-19 Across the World Income Distribution

The macroeconomic effects of the COVID-19 pandemic were most severe for emerging market economies, representing the middle of the world income distribution. This paper provides a quantitative economic theory for why emerging markets fared worse, on average, relative to advanced economies and low-income countries. To do so we adapt a workhorse incomplete-markets macro model to include epidemiological dynamics alongside key economic and demographic characteristics that distinguish countries of different income levels. We focus in particular on differences in lockdown stringency, public insurance programs, age distributions, healthcare capacity, and the sectoral composition of employment. The calibrated model correctly predicts the larger output losses and greater fatalities in emerging market economies, matching the data. Quantitatively, emerging markets fared especially poorly due to their high employment share in occupations requiring social interactions and their low level of pubic transfers, which leads economically vulnerable households to continue working in the market rather than sheltering at home. Low-income countries fared relatively better due mainly to their younger populations, whom are less susceptible to disease, and larger agricultural sectors, which require fewer social interactions.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 10⁹/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Epidemiologic Study of Intensive Care Unit Admission in South Korea: A Nationwide Population-Based Cohort Study from 2010 to 2019

We aimed to investigate the trends of intensive care unit (ICU) admissions in South Korea from 2010 to 2019. We included all adult patients (≥20 years old) who were admitted to the ICU during hospitalization from 2010 to 2019 in South Korea. There were 3,517,423 ICU admissions of 2,461,848 adult patients. Of the ICU admission cases, 66.8% (2,347,976/3,517,423) were surgery-associated admissions, and the rate of in-hospital mortality after ICU admission was 12.0% (422,155 patients). The most common diagnoses were diseases of the circulatory system (36.8%) and pneumonia (4%). The 30-day, 90-day, and 1-year mortality rates were 16.0%, 23.6%, and 33.3% in 2010, and these values slightly decreased by 2019 to 14.7%, 22.1%, and 31.7%, respectively. The proportions of continuous renal replacement therapy (CRRT) use and extracorporeal membrane oxygenation (ECMO) support were 2.0% and 0.3% in 2010, and these values gradually increased by 2019 to 4.7% and 0.8%, respectively. Although the age and cost of hospitalization among critically ill patients who were admitted to the ICU increased from 2010 to 2019, the mortality rate decreased slightly. Moreover, the proportions of ECMO support and CRRT use had increased in our South Korean cohort.

What are the perceptions of intensive care staff about their sedation practices when caring for a mechanically ventilated patient?: A systematic mixed-methods review

Background

Sedation is used alongside mechanical ventilation for patients in intensive care units internationally; its use is complex and multifaceted. Existing evidence shows that the ways health care professionals use sedation significantly impacts patient outcomes, including how long someone spends on a ventilator, length of stay in intensive care and recovery.

Objective

Our study aimed to systematically review and synthesize qualitative and quantitative evidence about how intensive care staff perceive sedation practices when looking after sedated and mechanically ventilated patients.

Design

We performed a systematic integrated mixed-methods literature review collecting qualitative and quantitative studies according to inclusion and exclusion criteria. Studies were included if they were published from 2009 and focused on perceptions of staff working in general adult intensive care units and caring for mechanically ventilated patients.

Settings

General adult intensive care units.

Participants

Health care professionals working in adult intensive care units.

Methods

Screening, data extraction and quality appraisal was undertaken by SV. Screening for inclusion and quality issues were reviewed by TR, TM and JS. The following databases: Embase, BNI, PubMed, Scopus, AMED, CINAHL, ASSIA, The Cochrane Library and Google Scholar. We used an assessment tool called the Mixed Methods Appraisal Tool. The studies were assessed and analysed by transforming the qualitative and quantitative data into 'text-in-context' statements. The statements were then synthesized using thematic analysis.

Results

Eighteen studies were included from ten countries, fourteen quantitative and four qualitative. Three overarching themes were identified: 'Variation in Decision Making', 'Challenges in Decision Making' and 'Thinking Outside the Box'. Existing studies revealed that there is considerable variation in most aspects of perceived sedation practice. Staff face challenges with interprofessional collaboration and sedation practice, and there are barriers to using sedation protocols and light sedation. There is also evidence that there is a need for health care professionals to develop coping strategies to help them facilitate lighter sedation.

Conclusions

A review of a decade of evidence shows that variation in decision making and challenges in decision making should be addressed to improve the care of the sedated and ventilated patient, and improve the caregiving experience for staff. Staff continue to require support with sedation practice, especially in light sedation. Research should now focus on how to help staff cope with looking after lightly sedated patients. In addition, future studies should focus on exploring sedation practices using qualitative methods as there is a dearth of qualitative evidence.

Tweetable abstract

Staff perceive a range of complex challenges that explain some of the variability in sedation practice for the ventilated patient in ICU.

Variation in the risk of death due to COVID-19: An international multicenter cohort study of hospitalized adults

BACKGROUND

There is wide variation in mortality among patients hospitalized with COVID-19. Whether this is related to patient or hospital factors is unknown.

OBJECTIVE

To compare the risk of mortality for patients hospitalized with COVID-19 and to determine whether the majority of that variation was explained by differences in patient characteristics across sites.

DESIGN, SETTING, AND PARTICIPANTS

An international multicenter cohort study of hospitalized adults with laboratory-confirmed COVID-19 enrolled from 10 hospitals in Ontario, Canada and 8 hospitals in Copenhagen, Denmark between January 1, 2020 and November 11, 2020.

MAIN OUTCOMES AND MEASURES

Inpatient mortality. We used a multivariable multilevel regression model to compare the in-hospital mortality risk across hospitals and quantify the variation attributable to patient-level factors.

RESULTS

There were 1364 adults hospitalized with COVID-19 in Ontario (n = 1149) and in Denmark (n = 215). In Ontario, the absolute risk of in-hospital mortality ranged from 12.0% to 39.8% across hospitals. Ninety-eight percent of the variation in mortality in Ontario was explained by differences in the characteristics of the patients. In Denmark, the absolute risk of inpatients ranged from 13.8% to 20.6%. One hundred percent of the variation in mortality in Denmark was explained by differences in the characteristics of the inpatients.

CONCLUSION

There was wide variation in inpatient COVID-19 mortality across hospitals, which was largely explained by patient-level factors, such as age and severity of presenting illness. However, hospital-level factors that could have affected care, including resource availability and capacity, were not taken into account. These findings highlight potential limitations in comparing crude mortality rates across hospitals for the purposes of reporting on the quality of care.

International variation in length of stay in intensive care units and the impact of patient-to-nurse ratios

OBJECTIVE

To assess variation in ICU length of stay between countries with varying patient-to-nurse ratios; to compare ICU length of stay of individual countries against an international benchmark.

DESIGN

Secondary analysis of the DecubICUs trial (performed on 15 May 2018).

SETTING

The study cohort included 12,794 adult ICU patients (57 countries). Only countries with minimally twenty patients discharged (or deceased) within 30 days of ICU admission were included.

MAIN OUTCOME MEASURE

Multivariate Cox regression was used to evaluate ICU length of stay, censored at 30 days, across countries and for patient-to-nurse ratio, adjusted for sex, age, admission type and Simplified Acute Physiology Score II. The resulting hazard ratios for countries, indicating longer or shorter length of stay than average, were plotted on a forest plot. Results by country were benchmarked against the overall length of stay using Kaplan-Meier curves.

RESULTS

Patients had a median ICU length of stay of 11 days (interquartile range, 4-27). Hazard ratio by country ranged from minimally 0.42 (95% confidence interval 0.35-0.51) for Greece, to maximaly1.94 (1.28-2.93) for Lithuania. The hazard ratio for patient-to-nurse was 0.96 (0.94-0.98), indicating that higher patient-to-nurse ratio results in longer length of stay.

CONCLUSIONS

Despite adjustment for case-mix, we observed significant heterogeneity of ICU length of stay in-between countries, and a significantly longer length of stay when patient-to-nurse ratio increases. Future studies determining underlying characteristics of individual ICUs and broader organisation of healthcare infrastructure within countries may further explain the observed heterogeneity in ICU length of stay.

External validation of the ProVent score for prognostication of 1-year mortality of critically ill patients with prolonged mechanical ventilation: a single-centre, retrospective observational study in Austria

OBJECTIVES

In critically ill patients requiring mechanical ventilation for at least 21 days, 1-year mortality can be estimated using the ProVent score, calculated from four variables (age, platelet count, vasopressor use and renal replacement therapy). We aimed to externally validate discrimination and calibration of the ProVent score and, if necessary, to update its underlying regression model.

DESIGN

Retrospective, observational, single-centre study.

SETTING

11 intensive care units at one tertiary academic hospital.

PATIENTS

780 critically ill adult patients receiving invasive mechanical ventilation for at least 21 days.

PRIMARY OUTCOME MEASURE

1-year mortality after intensive care unit discharge.

RESULTS

380 patients (49%) had died after 1 year. One-year mortality for ProVent scores from 0 to 5 were: 15%, 27%, 57%, 66%, 72% and 76%. Area under the receiver operating characteristic curve of the ProVent probability model was 0.76 (95% CI 0.72 to 0.79), calibration intercept was -0.43 (95% CI -0.59 to -0.27) and calibration slope was 0.76 (95% CI 0.62 to 0.89). Model recalibration and extension by inclusion of three additional predictors (total bilirubin concentration, enteral nutrition and surgical status) improved model discrimination and calibration. Decision curve analysis demonstrated that the original ProVent model had negative net benefit, which was avoided with the extended ProVent model.

CONCLUSIONS

The ProVent probability model had adequate discrimination but was miscalibrated in our patient cohort and, as such, could potentially be harmful. Use of the extended ProVent score developed by us could possibly alleviate this concern.

Towards definitions of critical illness and critical care using concept analysis

OBJECTIVE

As 'critical illness' and 'critical care' lack consensus definitions, this study aimed to explore how the concepts' are used, describe their defining attributes, and propose potential definitions.

DESIGN AND METHODS

We used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O'Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts' defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents.

RESULTS

Nine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, 'a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility', and of critical care as, 'the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.'

CONCLUSION

The concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.

Multicenter International Cohort Validation of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-sedation Scale

OBJECTIVE

In a multicenter, international cohort, we aimed to validate a modified Sequential Organ Failure Assessment (mSOFA) using the Richmond Agitation-Sedation Scale, hypothesized as comparable to the Glasgow Coma Scale (GCS)-based Sequential Organ Failure Assessment (SOFA).

SUMMARY BACKGROUND DATA

The SOFA score, whose neurologic component is based on the GCS, can predict intensive care unit (ICU) mortality. But, GCS is often missing in lieu of other assessments, such as the also reliable and validated Richmond Agitation Sedation Scale (RASS). Single-center data suggested an RASS-based SOFA (mSOFA) predicted ICU mortality.

METHODS

Our nested cohort within the prospective 2016 Fourth International Study of Mechanical Ventilation contains 4120 ventilated patients with daily RASS and GCS assessments (20,023 patient-days, 32 countries). We estimated GCS from RASS via a proportional odds model without adjustment. ICU mortality logistic regression models and c-statistics were constructed using SOFA (measured GCS) and mSOFA (measured RASS-estimated GCS), adjusted for age, sex, body-mass index, region (Europe, USA-Canada, Latin America, Africa, Asia, Australia-New Zealand), and postoperative status (medical/surgical).

RESULTS

Cohort-wide, the mean SOFA=9.4+/-2.8 and mean mSOFA = 10.0+/-2.3, with ICU mortality = 31%. Mean SOFA and mSOFA similarly predicted ICU mortality (SOFA: AUC = 0.784, 95% CI = 0.769-0.799; mSOFA: AUC = 0.778, 95% CI = 0.763-0.793, P = 0.139). Across models, other predictors of mortality included higher age, female sex, medical patient, and African region (all P < 0.001).

CONCLUSIONS

We present the first SOFA modification with RASS in a "real-world" international cohort. Estimating GCS from RASS preserves predictive validity of SOFA to predict ICU mortality. Alternative neurologic measurements like RASS can be viably integrated into severity of illness scoring systems like SOFA.

Predictors of ICU admission and patient outcome for traumatic brain injury in a Tanzanian referral hospital: Implications for improving treatment guidelines

Traumatic brain injuries (TBI) are a critical global health challenge, with disproportionate negative impact in low- and middle-income countries (LMICs). People who suffer severe TBI in LMICs are twice as likely to die than those in high-income countries, and survivors experience substantially poorer outcomes. In the hospital, patients with severe TBI are typically seen in intensive care units (ICU) to receive advanced monitoring and lifesaving treatment. However, the quality and outcomes of ICU care in LMICs are often unclear. We analyzed secondary data from a cohort of 605 adult patients who presented to the Emergency Department (ED) of a Tanzanian hospital with a moderate or severe TBI. We examined patient characteristics and performed two binary logistic regression models to assess predictors of ICU admission and patient outcome. Patients were often young (median age = 32, SD = 15), overwhelmingly male (88.9%), and experienced long delays from time of injury to presentation in the ED (median=12 h, SD = 168). A majority of patients (87.8%) underwent surgery and 55.6% ultimately had a "good recovery" with minimal disability, while 34.0% died. Patients were more likely to be seen in the ICU if they had worse baseline symptoms and were over age 60. TBI surgery conveyed a 37% risk reduction for poor TBI outcome. However, ICU patients had a 3.91 times higher risk of poor TBI outcome as compared to those not seen in the ICU, despite controlling for baseline symptoms. The findings point to the need for targeted interventions among young men, improvements in pre-hospital transportation and care, and continued efforts to increase the quality of surgical and ICU care in this setting. It is unlikely that poorer outcome among ICU patients was indicative of poorer care in the ICU; this finding was more likely due to lack of data on several factors that inform care decisions (e.g., comorbid conditions or injuries). Nevertheless, future efforts should seek to increase the capacity of ICUs in low-resource settings to monitor and treat TBI according to international guidelines, and should improve predictive modeling to identify risk for poor outcome.

Rates in Bronchiolitis Hospitalization, Intensive Care Unit Use, Mortality, and Costs From 2004 to 2018

IMPORTANCE

Over the last 2 decades, bronchiolitis guidelines and improvement efforts focused on supportive care and reducing unnecessary tests, treatments, and hospitalization. There have been limited population-based studies examining hospitalization outcomes over time.

OBJECTIVE

To describe rates and trends in bronchiolitis hospitalization, intensive care unit (ICU) use, mortality, and costs.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used population-based health administrative data from April 1, 2004, to March 31, 2018, to identify bronchiolitis encounters using hospital discharge diagnosis codes in Ontario, Canada. Children younger than 2 years with and without bronchiolitis hospitalization were included. Data were analyzed from January 2020 to July 2021.

MAIN OUTCOMES AND MEASURES

Bronchiolitis hospitalization per 1000 person-years, ICU use per 1000 hospitalizations, mortality per 100 000 person-years, and costs per 1000 person-years adjusted to 2018 Canadian dollars and reported in 2018 US dollars.

RESULTS

Among 2 336 446 included children, 1 199 173 (51.3%) were male. During the study period, 43 993 children (1.9%) younger than 2 years had 48 058 bronchiolitis hospitalizations at 141 hospitals. Bronchiolitis accounted for 48 058 of 360 920 all-cause hospitalizations (13.3%) and 215 654 of 2 566 348 all-cause hospital days (8.4%) in children younger than 2 years. Bronchiolitis hospitalization was stable over time, at 14.0 (95% CI, 13.6-14.4) hospitalizations per 1000 person-years in 2004-2005 and 12.7 (95% CI, 12.2-13.1) hospitalizations per 1000 person-years in 2017-2018 (annual percent change [APC], 0%; 95% CI, -1.6 to 1.6; P = .97). ICU admission increased significantly from 38.1 (95% CI, 32.2-44.8) per 1000 hospitalizations in 2004-2005 to 87.8 (95% CI, 78.3-98.0) per 1000 hospitalizations in 2017-2018 (APC, 7.2%; 95% CI, 5.4-8.9; P < .001). Over the study period, bronchiolitis mortality was 2.8 (95% CI, 2.3-3.4) per 100 000 person-years and remained stable (APC, 1.1%; 95% CI, -8.4 to 11.7; P = .85). Hospitalization costs per 1000 person-years increased from $49 640 (95% CI, $49 617-$49 663) in 2004-2005 to $58 632 (95% CI, $58 608-$58 657) in 2017-2018 (APC, 3.0%; 95% CI, 1.3-4.8; P = .002).

CONCLUSIONS AND RELEVANCE

From 2004 to 2018, bronchiolitis hospitalization and mortality rates remained stable; however, ICU use and costs increased substantially. This represents a major increase in high-intensity hospital care and costs for one of the most common and cumulatively expensive conditions in pediatric hospital care.

"HAP and VAP after Guidelines"

Nosocomial pneumonia is associated with worsened prognosis when diagnosed in intensive care unit (ICU), ranging from 12 to 48% mortality. The incidence rate of ventilation-acquired pneumonia tends to decrease below 15/1,000 intubation-day. Still, international guidelines are heterogeneous about diagnostic criteria because of inaccuracy of available methods. New entities have thus emerged concerning lower respiratory tract infection, namely ventilation-acquired tracheobronchitis (VAT), or ICU-acquired pneumonia (ICUAP), eventually requiring invasive ventilation (v-ICUAP), according to the type of ventilation support. The potential discrepancy with non-invasive methods could finally lead to underdiagnosis in almost two-thirds of non-intubated patients. Delayed diagnostic could explain in part the 2-fold increase in mortality of penumonia when invasive ventilation is initiated. Here we discuss the rationale underlying this new classification.Many situations can lead to misdiagnosis, even more when the invasive mechanical ventilation is initiated. The chest radiography lacks sntivity and specificity for diagnosing pneumonia. The place of chest computed tomography and lung ultrasonography for routine diagnostic of new plumonary infiltrate remain to be evaluated.Microbiological methods used to confirm the diagnostic can be heterogeneous. The development of molecular diagnostic tools may improve the adequacy of antimicrobial therapies of ventilated patients with pneumonia, but we need to further assess its impact in non-ventilated pneumonia.In this review we introduce distinction between hospital-acquired pneumonia according to the localization in the hospital and the oxygenation/ventilation mode. A clarification of definition is the first step to develop more accurate diagnostic strategies and to improve the patients' prognosis.

Health-related quality of life, anxiety and depression and physical recovery after critical illness - A prospective cohort study

BACKGROUND

Critical illness is often followed by mental and physical impairments. We aimed to assess the health-related quality of life (HRQoL), symptoms of anxiety and depression, and physical function in critically ill patients after discharge from the intensive care unit.

METHODS

For this prospective cohort study we included all available adult patients admitted to the ICU for >24 h during a 12-month period. Home visits took place at 3 and 12 months after discharge from the hospital and included Short-Form Health Survey (SF-36), Hospital Anxiety and Depression Scale, and Chelsea Critical Care Assessment Too (CPAx).

RESULTS

We visited 79 patients at 3 and 53 at 12 months. In patients with data from both visits the mental components SF-36 scores (median (IQR)) were 55 (43-63) at 3, and 58.5 (49.5-64) at 12 months; physical component SF-36 scores were 35 (28-45) at 3, and 36 (28-42) at 12 months. SF-36 subdomains of mental health, social functioning, and role emotional were close to normal. Vitality, bodily pain, general health, physical functioning, and role physical were severely affected. Incidences of anxiety and depression symptoms were 16%/8% at 3 and 13%/8% at 12 months) and physical function (CPAx) was 47 at both time points).

CONCLUSION

We found no change in HRQoL, anxiety, and depression, or physical function from 3 months to 1 year. Physical health-related quality of life was impaired at both time points. Subdomain scores for physical health-related quality of life were affected more than mental domains at both time points.

Characteristics and definitive outcomes of COVID-19 patients admitted to a secondary hospital intensive care unit in Sweden

BACKGROUND AND AIMS

Most published reports of COVID-19 Intensive Care Unit (ICU) patients are from large tertiary hospitals and often present short-term or incomplete outcome data. There are reports indicating that ICUs with fewer beds are associated with higher mortality. This study aimed to investigate the definitive outcome and patient characteristics of the complete first wave of COVID-19 patients admitted to ICU in a secondary hospital.

METHODS

In this prospective observational study, all patients with respiratory failure and a positive SARS-CoV-2 test admitted to Västerås Hospital ICU between 24 March and July 22, 2020 were included. The primary outcome was defined as 90-day mortality. Secondary outcomes included ICU length of stay, hospital length of stay, number of days with invasive ventilation, need for vasopressors/inotropes, and use of renal replacement therapy.

RESULTS

Fifty-three patients were included. Median age (range) was 59 (33-76) and 74% were men. Obesity and hypertension were the most common comorbidities and 45% of the patients were born outside Europe. Ninety-day mortality was 30%. Median ICU length of stay (interquartile range) was 14 (5-24) days and the duration of invasive mechanical ventilation 16 (12-26) days. No patients received dialysis at 90-day follow-up.

CONCLUSION

In this cohort of COVID-19 patients treated in a secondary hospital ICU, mortality rates were low compared to early studies from China, Italy, and the United States, but similar to other government-funded hospitals in Scandinavia. A preparatory reorganization enabled an increase in ICU capacity, hence avoiding an overwhelmed intensive care organization.

Post-Intensive Care Syndrome in Covid-19 Patients Discharged From the Intensive Care Unit

Patients with Covid-19, after discharge from the intensive care unit (ICU), experience some psychological, physical, and cognitive disorders, which is known as the post-intensive care syndrome and has adverse effects on patients and their families. The aim of this study was to evaluate the post-intensive care syndrome and its predictors in Covid-19 patients discharged from the ICU. In this study, 84 Covid-19 patients discharged from the ICU were selected by census method based on inclusion and exclusion criteria. After completing the demographic information, the Healthy Aging Brain Care Monitor Self Report Tool was used to assess post-intensive care syndrome. Sixty-nine percent of participants experienced different degrees of post-intensive care syndrome, and its mean score was 8.86 ± 12.50; the most common disorder was related to the physical dimension. Among individual social variables, age and duration after discharge were able to predict 12.3% and 8.4% of the variance of post-intensive care syndrome, respectively. Covid-19 patients who are admitted to the ICU, after discharge from the hospital, face cognitive, psychological, and functional disorders, and there is a need for planning to prevent, follow up, and care for them by health care providers in the hospice and palliative care centers.

Primary palliative care integrated model in paediatric ICU: an international cross-sectional study

OBJECTIVES

Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC.

METHODS

International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models.

RESULTS

High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores.

CONCLUSIONS

All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN12556149.

A Macroeconomic SIR Model for COVID-19

The COVID-19 pandemic and subsequent lockdowns highlight the close and delicate relationship between a country’s public health and economic health. Models that combine macroeconomic factors with traditional epidemic dynamics to calculate the impacts of a disease outbreak are therefore extremely useful for policymakers seeking to evaluate the best course of action in such a crisis. We developed a macroeconomic SIR model that considers herd immunity, behavior-dependent transmission rates, remote workers, and the indirect externalities of lockdowns. It is formulated as an exit time control problem where a social planner is able to prescribe separate levels of the lockdown low-risk and high-risk portions of the adult population. The model predicts that by considering the possibility of reaching herd immunity, high-risk individuals are able to leave lockdown sooner than in models where herd immunity is not considered. Additionally, a behavior-dependent transmission rate (which represents increased personal caution in response to increased infection levels) can lower both output loss and total mortality. Overall, the model-determined optimal lockdown strategy, combined with individual actions to slow virus transmission, is able to reduce total mortality to one-third of the model-predicted no-lockdown level of mortality.

Epidemiology and clinical characteristics of patients discharged from the ICU in a vegetative or minimally conscious state

PURPOSE

A significant percentage of patients are discharged from intensive care units (ICU) with disorders of counciousness (DoC). The aim of this retrospective, case-control study was to compare patients discharged from the ICU in a vegetative state (VS) or minimally conscious state (MCS) and the rest of ICU survivors, and to identify independent predictors of DoC among ICU survivors.

METHODS

Data from 14,368 adult ICU survivors identified in a Silesian Registry of Intensive Care Units (active in the Silesian Region of Poland between October 2010 and December 2019) were analyzed. Patients discharged from the ICU in a VS or MCS were compared to the remaining ICU survivors. Pre-admission and admission variables that independently influence ICU discharge with DoC were identified.

RESULTS

Among the 14,368 analyzed adult ICU survivors, 1,064 (7.4%) were discharged from the ICU in a VS or MCS. The percentage of patients discharged from the ICU with DoC was similar in all age groups. Compared to non- DoC ICU patients, they had a higher mean APACHE II and SAPS III score at admission. Independent variables affecting ICU discharge with DoC included unconsciousness at ICU admission, cardiac arrest and craniocerebral trauma as primary cause of ICU admission, as well as a history of previous chronic neurological disorders and cerebral stroke (p<0.001).

CONCLUSION

Discharge in a VS and MCS was relatively frequent among ICU survivors. Discharge with DoC was more likely among patients who were unconscious at admission and admitted to the ICU due to cardiac arrest or craniocerebral trauma.

Importance of patient bed pathways and length of stay differences in predicting COVID-19 hospital bed occupancy in England

BACKGROUND

Predicting bed occupancy for hospitalised patients with COVID-19 requires understanding of length of stay (LoS) in particular bed types. LoS can vary depending on the patient's "bed pathway" - the sequence of transfers of individual patients between bed types during a hospital stay. In this study, we characterise these pathways, and their impact on predicted hospital bed occupancy.

METHODS

We obtained data from University College Hospital (UCH) and the ISARIC4C COVID-19 Clinical Information Network (CO-CIN) on hospitalised patients with COVID-19 who required care in general ward or critical care (CC) beds to determine possible bed pathways and LoS. We developed a discrete-time model to examine the implications of using either bed pathways or only average LoS by bed type to forecast bed occupancy. We compared model-predicted bed occupancy to publicly available bed occupancy data on COVID-19 in England between March and August 2020.

RESULTS

In both the UCH and CO-CIN datasets, 82% of hospitalised patients with COVID-19 only received care in general ward beds. We identified four other bed pathways, present in both datasets: "Ward, CC, Ward", "Ward, CC", "CC" and "CC, Ward". Mean LoS varied by bed type, pathway, and dataset, between 1.78 and 13.53 days. For UCH, we found that using bed pathways improved the accuracy of bed occupancy predictions, while only using an average LoS for each bed type underestimated true bed occupancy. However, using the CO-CIN LoS dataset we were not able to replicate past data on bed occupancy in England, suggesting regional LoS heterogeneities.

CONCLUSIONS

We identified five bed pathways, with substantial variation in LoS by bed type, pathway, and geography. This might be caused by local differences in patient characteristics, clinical care strategies, or resource availability, and suggests that national LoS averages may not be appropriate for local forecasts of bed occupancy for COVID-19.

TRIAL REGISTRATION

The ISARIC WHO CCP-UK study ISRCTN66726260 was retrospectively registered on 21/04/2020 and designated an Urgent Public Health Research Study by NIHR.

The association between various indicators of hospital capacity, age category, and the number of screening tests performed with case fatality rate and recovery rate during the COVID-19 disease pandemic

BACKGROUND

The COVID-19-related deaths are growing rapidly around the world, especially in Europe and the United States.

PURPOSE

In this study we attempt to measure the association of these variables with case fatality rate (CFR) and recovery rate (RR) using up-to-date data from around the world.

METHODS

Data were collected from eight global databases. According to the raw data of countries, the CFR and RR and their relationship with different predictors was compared for countries with 1,000 or more cases of COVID-19 confirmed cases.

RESULTS

There were no significant correlation between the CFR and number of hospital beds per 1,000 people, proportion of population aged 65 and older ages, and the number of computed tomography per one million inhabitants. Furthermore, based on the continents-based subgroup univariate regression analysis, the population (R2 = 0.37, P = 0.047), GPD (R2 = 0.80, P < 0.001), number of ICU Beds per 100,000 people (R2 = 0.93, P = 0.04), and number of CT per one million inhabitants (R2 = 0.78, P = 0.04) were significantly correlated with CFR in America. Moreover, the income-based subgroups analysis showed that the gross domestic product (R2 = 0.30, P = 0.001), number of ICU Beds per 100,000 people (R2 = 0.23, P = 0.008), and the number of ventilator (R2 = 0.46, P = 0.01) had significant correlation with CFR in high-income countries.

CONCLUSIONS

The level of country's preparedness, testing capacity, and health care system capacities also are among the important predictors of both COVID-19 associated mortality and recovery. Thus, providing up-to-date information on the main predictors of COVID-19 associated mortality and recovery will hopefully improve various countries hospital resource allocation, testing capacities, and level of preparedness.

Day-to-day progression of vital-sign circadian rhythms in the intensive care unit

Background

Disrupted vital-sign circadian rhythms in the intensive care unit (ICU) are associated with complications such as immune system disruption, delirium and increased patient mortality. However, the prevalence and extent of this disruption is not well understood. Tools for its detection are currently limited.

Methods

This paper evaluated and compared vital-sign circadian rhythms in systolic blood pressure, heart rate, respiratory rate and temperature. Comparisons were made between the cohort of patients who recovered from the ICU and those who did not, across three large, publicly available clinical databases. This comparison included a qualitative assessment of rhythm profiles, as well as quantitative metrics such as peak–nadir excursions and correlation to a demographically matched ‘recovered’ profile.

Results

Circadian rhythms were present at the cohort level in all vital signs throughout an ICU stay. Peak–nadir excursions and correlation to a ‘recovered’ profile were typically greater throughout an ICU stay in the cohort of patients who recovered, compared to the cohort of patients who did not.

Conclusions

These results suggest that vital-sign circadian rhythms are typically present at the cohort level throughout an ICU stay and that quantitative assessment of these rhythms may provide information of prognostic use in the ICU.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03574-w.

Machine Learning Approach to Predicting COVID-19 Disease Severity Based on Clinical Blood Test Data: Statistical Analysis and Model Development

Background

Accurate prediction of the disease severity of patients with COVID-19 would greatly improve care delivery and resource allocation and thereby reduce mortality risks, especially in less developed countries. Many patient-related factors, such as pre-existing comorbidities, affect disease severity and can be used to aid this prediction.

Objective

Because rapid automated profiling of peripheral blood samples is widely available, we aimed to investigate how data from the peripheral blood of patients with COVID-19 can be used to predict clinical outcomes.

Methods

We investigated clinical data sets of patients with COVID-19 with known outcomes by combining statistical comparison and correlation methods with machine learning algorithms; the latter included decision tree, random forest, variants of gradient boosting machine, support vector machine, k-nearest neighbor, and deep learning methods.

Results

Our work revealed that several clinical parameters that are measurable in blood samples are factors that can discriminate between healthy people and COVID-19–positive patients, and we showed the value of these parameters in predicting later severity of COVID-19 symptoms. We developed a number of analytical methods that showed accuracy and precision scores >90% for disease severity prediction.

Conclusions

We developed methodologies to analyze routine patient clinical data that enable more accurate prediction of COVID-19 patient outcomes. With this approach, data from standard hospital laboratory analyses of patient blood could be used to identify patients with COVID-19 who are at high risk of mortality, thus enabling optimization of hospital facilities for COVID-19 treatment.

A Closer Look Into Global Hospital Beds Capacity and Resource Shortages During the COVID-19 Pandemic

BACKGROUND

As the COVID-19 pandemic continues, there is a question of whether hospitals have adequate resources to manage patients. We aim to investigate global hospital bed (HB), acute care bed (ACB), and intensive care unit (ICU) bed capacity and determine any correlation between these hospital resources and COVID-19 mortality.

METHOD

Cross-sectional study utilizing data from the World Health Organization (WHO) and other official organizations regarding global HB, ACB, ICU bed capacity, and confirmed COVID-19 cases/mortality. Descriptive statistics and linear regression were performed.

RESULTS

A total of 183 countries were included with a mean of 307.1 HBs, 413.9 ACBs, and 8.73 ICU beds/100,000 population. High-income regions had the highest mean number of ICU beds (12.79) and HBs (402.32) per 100,000 population whereas upper middle-income regions had the highest mean number of ACBs (424.75) per 100,000. A weakly positive significant association was discovered between the number of ICU beds/100,000 population and COVID-19 mortality. No significant associations exist between the number of HBs or ACBs per 100,000 population and COVID-19 mortality.

CONCLUSIONS

Global COVID-19 mortality rates are likely affected by multiple factors, including hospital resources, personnel, and bed capacity. Higher income regions of the world have greater ICU, acute care, and hospital bed capacities. Mandatory reporting of ICU, acute care, and hospital bed capacity/occupancy and information relating to coronavirus should be implemented. Adopting a tiered critical care approach and targeting the expansion of space, staff, and supplies may serve to maximize the quality of care during resurgences and future disasters.

Adequacy of workforce - are there enough critical care doctors in the US-post COVID?

PURPOSE OF REVIEW

The ICU is a complex ecosystem in which intensive care physicians, advanced practice providers (APPs), pharmacists, and respiratory therapists work in concert to take care of critically ill patients. The SARS COV2 pandemic highlighted weaknesses in the American healthcare system. This article explores the ability of American healthcare to adapt to this challenge.

RECENT FINDINGS

With the COVID-19 pandemic, intensivists, and ventilators have been identified as the most critical components leading to shortages in ICU capacity. Anesthesiologists play a unique role in being able to provide 'flex capacity' with critical care staffing, space, and equipment (post-anesthesia care units, operating rooms, and ventilators). With the advent of APPs, intensive care physician staffing ratios may potentially be increased to cover patients safely in a physician-led team model. Tele-medicine expands this further and can allow hospital coordination for optimizing ICU bed use.

SUMMARY

Although intensivists have been able to take care of the increased ICU caseload during the COVID-19 pandemic through recruiting other specialties, the question of what is the appropriate staffing model for the future is yet to be elucidated. Creating stronger multidisciplinary care teams that have the capacity to flex up critical care capacity may be the most prudent longer-term solution.

Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review

The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.

On the emergence, spread and resistance of Candida auris: host, pathogen and environmental tipping points

Over a decade ago, a multidrug-resistant nosocomial fungus Candida auris emerged worldwide and has since become a significant challenge for clinicians and microbiologists across the globe. A resilient pathogen, C. auris survives harsh disinfectants, desiccation and high-saline environments. It readily colonizes the inanimate environment, susceptible patients and causes invasive infections that exact a high toll. Prone to misidentification by conventional microbiology techniques, C. auris rapidly acquires multiple genetic determinants that confer multidrug resistance. Whole-genome sequencing has identified four distinct clades of C. auris, and possibly a fifth one, in circulation. Even as our understanding of this formidable pathogen grows, the nearly simultaneous emergence of its distinct clades in different parts of the world, followed by their rapid global spread, remains largely unexplained. We contend that certain host-pathogen-environmental factors have been evolving along adverse trajectories for the last few decades, especially in regions where C. auris originally appeared, until these factors possibly reached a tipping point to compel the evolution, emergence and spread of C. auris. Comparative genomics has helped identify several resistance mechanisms in C. auris that are analogous to those seen in other Candida species, but they fail to fully explain how high-level resistance rapidly develops in this yeast. A better understanding of these unresolved aspects is essential not only for the effective management of C. auris patients, hospital outbreaks and its global spread but also for forecasting and tackling novel resistant pathogens that might emerge in the future. In this review, we discuss the emergence, spread and resistance of C. auris, and propose future investigations to tackle this resilient pathogen.

Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018

Background

Globally, mortality rates of patients admitted to the intensive care unit (ICU) have decreased over the last two decades. However, evaluations of the temporal trends in the characteristics and outcomes of ICU patients in Asia are limited. The objective of this study was to describe the characteristics and risk adjusted outcomes of all patients admitted to publicly funded ICUs in Hong Kong over a 11-year period. The secondary objective was to validate the predictive performance of Acute Physiology And Chronic Health Evaluation (APACHE) IV for ICU patients in Hong Kong.

Methods

This was an 11-year population-based retrospective study of all patients admitted to adult general (mixed medical-surgical) intensive care units in Hong Kong public hospitals. ICU patients were identified from a population electronic health record database. Prospectively collected APACHE IV data and clinical outcomes were analysed.

Results

From 1 April 2008 to 31 March 2019, there were a total of 133,858 adult ICU admissions in Hong Kong public hospitals. During this time, annual ICU admissions increased from 11,267 to 14,068, whilst hospital mortality decreased from 19.7 to 14.3%. The APACHE IV standard mortality ratio (SMR) decreased from 0.81 to 0.65 during the same period. Linear regression demonstrated that APACHE IV SMR changed by − 0.15 (95% CI − 0.18 to − 0.11) per year (Pearson’s R = − 0.951, p < 0.001). Observed median ICU length of stay was shorter than that predicted by APACHE IV (1.98 vs. 4.77, p < 0.001). C-statistic for APACHE IV to predict hospital mortality was 0.889 (95% CI 0.887 to 0.891) whilst calibration was limited (Hosmer–Lemeshow test p < 0.001).

Conclusions

Despite relatively modest per capita health expenditure, and a small number of ICU beds per population, Hong Kong consistently provides a high-quality and efficient ICU service. Number of adult ICU admissions has increased, whilst adjusted mortality has decreased over the last decade. Although APACHE IV had good discrimination for hospital mortality, it overestimated hospital mortality of critically ill patients in Hong Kong.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-020-00513-9.

Increased insulin resistance in intensive care: longitudinal retrospective analysis of glycaemic control patients in a New Zealand ICU

BACKGROUND

Critical care populations experience demographic shifts in response to trends in population and healthcare, with increasing severity and/or complexity of illness a common observation worldwide. Inflammation in critical illness impacts glucose-insulin metabolism, and hyperglycaemia is associated with mortality and morbidity. This study examines longitudinal trends in insulin sensitivity across almost a decade of glycaemic control in a single unit.

METHODS

A clinically validated model of glucose-insulin dynamics is used to assess hour-hour insulin sensitivity over the first 72 h of insulin therapy. Insulin sensitivity and its hour-hour percent variability are examined over 8 calendar years alongside severity scores and diagnostics.

RESULTS

Insulin sensitivity was found to decrease by 50-55% from 2011 to 2015, and remain low from 2015 to 2018, with no concomitant trends in age, severity scores or risk of death, or diagnostic category. Insulin sensitivity variability was found to remain largely unchanged year to year and was clinically equivalent (95% confidence interval) at the median and interquartile range. Insulin resistance was associated with greater incidence of high insulin doses in the effect saturation range (6-8 U/h), with the 75th percentile of hourly insulin doses rising from 4-4.5 U/h in 2011-2014 to 6 U/h in 2015-2018.

CONCLUSIONS

Increasing insulin resistance was observed alongside no change in insulin sensitivity variability, implying greater insulin needs but equivalent (variability) challenge to glycaemic control. Increasing insulin resistance may imply greater inflammation and severity of illness not captured by existing severity scores. Insulin resistance reduces glucose tolerance, and can cause greater incidence of insulin saturation and resultant hyperglycaemia. Overall, these results have significant clinical implications for glycaemic control and nutrition management.

Identifying subpopulations of septic patients: A temporal data-driven approach

Sepsis is one of the deadliest diseases in North America and in spite of the vast amount of research on this topic there is still uncertainty in the outcome of sepsis treatments. This study aimed at investigating the informativeness of temporal electronic health records (EHR) in stratifying septic patients and identifying subpopulations of septic patients with similar trajectories and clinical needs. We performed hierarchical clustering and Density-Based Spatial Clustering of Applications with Noise (DBSCAN) analyses using data from septic patients in the MIMIC III intensive care unit database. The t-Distributed Stochastic Neighbor Embedding (t-SNE) method was utilized to map patients to a two-dimensional space. We utilized silhouette index and cluster-wise stability assessment by resampling to investigate the validity of the clusters. The hierarchical clustering with Euclidean metric identified twelve clinically recognizable subgroups that demonstrated different characteristics in spite of sharing common conditions. Our results demonstrated that data-driven approaches can help in customizing care platforms for septic patients by identifying similar clinically relevant groups.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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