Creation and Expansion of a Mixed Patient Intermediate Care Unit to Improve ICU Capacity

OBJECTIVES

ICU capacity strain is associated with worsened outcomes. Intermediate care units (IMCs) comprise one potential option to offload ICUs while providing appropriate care for intermediate acuity patients, but their impact on ICU capacity has not been thoroughly characterized. The aims of this study are to describe the creation of a medical-surgical IMC and assess how the IMC affected ICU capacity.

DESIGN

Descriptive report with retrospective cohort review.

SETTING

Six hundred seventy-three-bed tertiary care academic medical center with 77 ICU beds.

PATIENTS

Adult inpatients who were admitted to the IMC.

INTERVENTIONS

An interdisciplinary working group created an IMC which was located on a general ward. The IMC was staffed by hospitalists and surgeons and supported by critical care consultants. The initial maximum census was three, but this number increased to six in response to heightened critical care demand. IMC admission criteria also expanded to include advanced noninvasive respiratory support defined as patients requiring high-flow nasal cannula, noninvasive positive pressure ventilation, or mechanical ventilation in patients with tracheostomies.

MEASUREMENTS AND MAIN RESULTS

The primary outcome entailed the number of ICU bed-days saved. Adverse outcomes, including ICU transfer, intubation, and death, were also recorded. From August 2021 to July 2022, 230 patients were admitted to the IMC. The most frequent IMC indications were respiratory support for medical patients and post-operative care for surgical patients. A total of 1023 ICU bed-days were made available. Most patients were discharged from the IMC to a general ward, while 8% of all patients required transfer to an ICU within 48 hours of admission. Intubation (2%) and death (1%) occurred infrequently within 48 hours of admission. Respiratory support was the indication associated with the most ICU transfers.

CONCLUSIONS

Despite a modest daily census, an IMC generated substantial ICU bed capacity during a time of peak critical care demand.

P3594Transition from 4th to 5th generation cardiac troponin T: testing patterns, myocardial infarction incident rates, and resource utilization across a multicenter United States regional healthcare system

Background

Several high-sensitivity cardiac troponin (cTn) assays have been cleared by the United States (US) Food and Drug Administration (FDA) for clinical use. Although some of them have been used outside the US for some time, there is limited experience thus far across US sites. Following FDA clearance of the Roche 5th Gen cTnT assay in January 2017, a multicenter US regional healthcare system introduced this more sensitive cTnT assay into clinical practice in September 2018.

Purpose

To examine cTn testing patterns, incidence of acute myocardial infarction (MI), and resource utilization before and after implementation of the 5th Gen cTnT assay across a large US healthcare system.

Methods

Using electronic-health records reporting software (Cogito SlicerDicer, EPIC), administrative data was examined to evaluate the transition (4-months before and after implementation) from the 4th to 5th Gen cTnT assays across 16 hospitals but not the major hub hospital of the system that transitioned at a separate time. Adult patient visits (emergency and hospital encounters), cTnT testing, incidence of chest discomfort and acute MI, and resource utilization, including hospital admissions, were examined during the transition period.

Results

98,558 adult ED patient visits occurred during an 8-month period across 16 hospitals, including 50,485 and 48,073 patient visits before (5/12/18 – 9/11/18) and after (9/12/18 – 1/11/19) implementation of the 5th Gen cTnT assay respectively. cTnT testing occurred in 20% (range 8.9–34.8%) of all ED visits, with testing performed in the absence of chest pain in 54% (range 37–67%) of cases. Acute MI was diagnosed in 5.6% (n=561) of cases using the 4th Gen cTnT assay as compared to 6.6% (n=608) of cases using the 5th Gen cTnT assay (absolute difference 1.0%, 95% CI: 0.32–1.68, p=0.004). Much of the increase in MI diagnoses were in women (2.2% vs. 2.8%, p=0.008). The proportion of ED patients requiring hospital admission did not differ between pre- and post-implementation periods (24.1% vs. 23.6%, p=0.4); however, among the subset of patients with chest pain, fewer admissions occurred post-implementation (17.9% vs. 15.8%, p=0.006). There was no increase in echocardiography (9.3% vs. 8.4%), coronary angiography (2.9% vs. 3.1%), or cardiac consultations (7.3% vs. 7.3%) utilization post-implementation.

Conclusions

Cardiac troponin testing occurs in nearly 20% of ED visits in a large multicenter regional healthcare system. About half of all tests are ordered in the absence of chest pain, with a low MI rate observed among the patients undergoing testing. Following implementation of the 5th Gen cTnT assay, testing rates/patterns remained unchanged, with a small but significant increase in MI diagnoses, primarily due to more women being diagnosed with MI. Fewer ED patients with chest pain required admission. Despite using a more sensitive cTn assay, hospital admissions and resource utilization did not increase post-implementation.

The cost of a hot drink scald

Approximately 6400 children per year are admitted to UK hospitals for treatment of burns [National Burn Care Review Committee Report (NBCRC). Standards and Strategy for Burn Care: a review of burn care in the British Isles. 2001.]. This paper investigates the financial costs involved in the management of uncomplicated, minor paediatric scalds. Three cases (2-4% TBSA scalds) were studied to quantify consumables used, services required during management and costs obtained from appropriate Purchasing Departments and Directorate Accountants. Management in all cases involved a general anaesthetic for cleaning of wounds, application of BioBrane (Bertek Pharmaceuticals) and dressings, observation on Children's Ward and discharge following wound review at 48 h. The calculated mean average cost per case was pound1850. In the period 01/12/2002-30/11/2003, 144 children were admitted to Frenchay hospital, Bristol, for treatment of a minor burn or scald (less than 10%TBSA). This caseload is therefore estimated to currently cost pound266,400 per year. These findings may facilitate improved planning for future resource allocation and could also contribute evidence towards the cost effectiveness of prevention strategies.

Coping with domestic violence: control attributions, dysphoria, and hopelessness

We investigated the influence of control judgments and coping style on emotional reactions to domestic violence utilizing the framework of hopelessness theory. We assessed abuse severity, control attributions, coping, dysphoric symptoms, and hopelessness in 70 battered women recruited from 12 domestic violence agencies. Respondents reported dysphoria but not hopelessness. Increased reports of dysphoria were associated with higher levels of self-blame and avoidance coping and lower levels of problem-focused coping. Increased problem-focused coping was associated with decreased hopelessness. Perceived control over current abuse was not related to dysphoria. High expectations for control over future events were associated with decreased dysphoria. We discuss our results in terms of their application to attributional accounts of emotional reactions to battering.

Assessment of adult and neonatal reproductive parameters in Sprague-Dawley rats exposed to propylene glycol monomethyl ether vapors for two generations

This study evaluated propylene glycol monomethyl ether (PGME) in a rat 2-generation reproduction study, which included non-traditional study end points, such as sperm count and motility, developmental landmarks, estrous cyclicity, and weanling organ weights. Groups of 30 male and 30 female Sprague-Dawley rats (6-weeks-old) were exposed to 0, 300, 1000, or 3000 ppm of PGME vapors via inhalation for 6 hours/day, 5 days/week prior to mating, and 6 hours/day, 7 days/week during mating, gestation, and lactation, for 2 generations. These concentrations corresponded to estimated oral equivalent doses of 0, 396, 1325, or 3974 mg/kg/day. At 3000 ppm, toxicity in the P1 and P2 adults was marked, as evidenced by sedation during and after exposure, and mean body weights which were as much as 21% lower than controls. This marked parental toxicity was accompanied by lengthened estrous cycles, decreased fertility, decreased ovary weights, and histologic ovarian atrophy in maternal rats. In the offspring from these dams, decreased body weights, reduced survival and litter size, slight delays in puberty onset, and histologic changes in liver and thymus in the F1 and F2 offspring were observed. The nature of the reproductive/neonatal effects and their close individual animal correlation with decreased maternal body weights suggested that these effects were secondary to general toxicity and/or nutritional stress. No such reproductive/neonatal effects were observed at 1000 ppm, a concentration which caused less marked, but significant body weight effects without sedation. There were no treatment-related effects of any kind noted at 300 ppm of PGME. Therefore, the no-observable-effect level (NOEL) for reproductive/neonatal effects was 1000 ppm, and that for parental toxicity was 300 ppm.

Estimating inbreeding from the Faculty Office Registers, 1534-1540

Estimates of inbreeding are rather scarce for British populations. A number of studies, especially of Scottish island populations, have focused on pedigree analysis, whilst others have used survey methods or inference from isonymy. By comparison with continental Europe, however, little is known of the historical development of inbreeding. This is undoubtedly due to the lack of evidence from dispensations to marry blood relatives, which are routinely available in the records of marriage of the Roman Catholic church. The paper uses as its data source the Faculty Office Registers, 1534-1540, which were the product of a new system of issuing dispensations following the Dispensations Act of 1533, and which are among the earliest administrative records of the Church of England, founded as a result of Henry VIII's breach with Rome. Dispensations are recorded in the Faculty Office until 1540, when all prohibitions on marriage beyond the proscribed relationships laid down in Leviticus were lifted. The data suggest surprisingly low levels of consanguineous marriage, including a lack of first-cousin marriages. These findings are discussed in terms of the reliability of the archive, and of the social and religious views attending marriage between blood relatives in the medieval and early modern periods.

Illusion of control: invulnerability to negative affect and depressive symptoms after laboratory and natural stressors

We examined whether individual differences in susceptibility to the illusion of control predicted differential vulnerability to depressive responses after a laboratory failure and naturally occurring life stressors. The illusion of control decreased the likelihood that subjects (N = 145) would (a) show immediate negative mood reactions to the laboratory failure, (b) become discouraged after naturally occurring negative life events, and (c) experience increases in depressive symptoms a month later given the occurrence of a high number of negative life events. In addition, the stress-moderating effect of the illusion of control on later depressive symptoms appeared to be mediated in part by its effect on reducing the discouragement subjects experienced from the occurrence of negative life events. These findings provide support for the hopelessness theory of depression and for the optimistic illusion-mental health link.

Illusion of control: Invulnerability to negative affect and depressive symptoms after laboratory and natural stressors

We examined whether individual differences in susceptibility to the illusion of control predicted differential vulnerability to depressive responses after a laboratory failure and naturally occurring life stressors. The illusion of control decreased the likelihood that subjects (N = 145) would (a) show immediate negative mood reactions to the laboratory failure, (b) become discouraged after naturally occurring negative life events, and (c) experience increases in depressive symptoms a month later given the occurrence of a high number of negative life events. In addition, the stress-moderating effect of the illusion of control on later depressive symptoms appeared to be mediated in part by its effect on reducing the discouragement subjects experienced from the occurrence of negative life events. These findings provide support for the hopelessness theory of depression and for the optimistic illusion-mental health link.