Clinical outcomes of non-COVID-19 orthopaedic patients admitted during the COVID-19 pandemic: a multi-centre interrupted time series analysis across hospitals in six different countries

OBJECTIVES

To assess across seven hospitals from six different countries the extent to which the COVID-19 pandemic affected the volumes of orthopaedic hospital admissions and patient outcomes for non-COVID-19 patients admitted for orthopaedic care.

DESIGN

A multi-centre interrupted time series (ITS) analysis.

SETTING

Seven hospitals from six countries who collaborated within the Global Health Data@Work collaborative.

PARTICIPANTS

Non-COVID-19 patients admitted for orthopaedic care during the pre-pandemic (January/2018-February/2020) and COVID-19 pandemic (March/2020-June/2021) period. Admissions were categorised as: (1) acute admissions (lower limb fractures/neck of femur fractures/pathological fractures/joint dislocations/upper limb fractures); (2) subacute admissions (bone cancer); (3) elective admissions (osteoarthritis).

OUTCOME MEASURES

Monthly observed versus expected ratios (O/E) were calculated for in-hospital mortality, long (upper-decile) length-of-stay and hospital readmissions, with expected rates calculated based on case-mix. An ITS design was used to estimate the change in level and/or trend of the monthly O/E ratio by comparing the COVID-19 pandemic with the pre-pandemic period.

RESULTS

69 221 (pre-pandemic) and 22 940 (COVID-19 pandemic) non-COVID-19 orthopaedic patient admissions were included. Admission volumes were reduced during the COVID-19 pandemic for all admission categories (range: 33%-45%), with more complex patients treated as shown by higher percentages of patients admitted with ≥1 comorbidity (53.8% versus 49.8%, p<0.001). The COVID-19 pandemic was not associated with significant changes in patient outcomes for most diagnostic groups. Only for patients diagnosed with pathological fractures (pre-pandemic n=1671 and pandemic n=749), the COVID-19 pandemic was significantly associated with an immediate mortality reduction (level change of -77.7%, 95% CI -127.9% to -25.7%) and for lower limb fracture patients (pre-pandemic n=9898 and pandemic n=3307) with a significantly reduced trend in readmissions (trend change of -6.3% per month, 95% CI -11.0% to -1.6%).

CONCLUSIONS

Acute, subacute, as well as elective orthopaedic hospital admissions volumes were reduced in all global participating hospitals during the COVID-19 pandemic, while overall patient outcomes for most admitted non-COVID-19 patients remained the same despite the strain caused by the surge of COVID-19 patients.

REVersal of nEuromusculAr bLocking Agents in Patients Undergoing General Anaesthesia (REVEAL Study)

Background: Neuromuscular blocking agent (NMBA) monitoring and reversals are key to avoiding residual curarization and improving patient outcomes. Sugammadex is a NMBA reversal with favorable pharmacological properties. There is a lack of real-world data detailing how the diffusion of sugammadex affects anesthetic monitoring and practice. Methods: We conducted an electronic health record analysis study, including all adult surgical patients undergoing general anesthesia with orotracheal intubation, from January 2016 to December 2019, to describe changes and temporal trends of NMBAs and NMBA reversals administration. Results: From an initial population of 115,046 surgeries, we included 37,882 procedures, with 24,583 (64.9%) treated with spontaneous recovery from neuromuscular block and 13,299 (35.1%) with NMBA reversals. NMBA reversals use doubled over 4 years from 25.5% to 42.5%, mainly driven by sugammadex use, which increased from 17.8% to 38.3%. Rocuronium increased from 58.6% (2016) to 94.5% (2019). Factors associated with NMBA reversal use in the multivariable analysis were severe obesity (OR 3.33 for class II and OR 11.4 for class III obesity, p-value < 0.001), and high ASA score (OR 1.47 for ASA III). Among comorbidities, OSAS, asthma, and other respiratory diseases showed the strongest association with NMBA reversal administration. Conclusions: Unrestricted availability of sugammadex led to a considerable increase in pharmacological NMBA reversal, with rocuronium use also rising. More research is needed to determine how unrestricted and safer NMBA reversal affects anesthesia intraoperative monitoring and practice.

The effect of COVID-19 epidemic on vital signs in hospitalized patients: a pre-post heat-map study from a large teaching hospital

The Lombardy SARS-CoV-2 outbreak in February 2020 represented the beginning of COVID-19 epidemic in Italy. Hospitals were flooded by thousands of patients with bilateral pneumonia and severe respiratory, and vital sign derangements compared to the standard hospital population. We propose a new visual analysis technique using heat maps to describe the impact of COVID-19 epidemic on vital sign anomalies in hospitalized patients. We conducted an electronic health record study, including all confirmed COVID-19 patients hospitalized from February 21st, 2020 to April 21st, 2020 as cases, and all non-COVID-19 patients hospitalized in the same wards from January 1st, 2018 to December 31st, 2018. All data on temperature, peripheral oxygen saturation, respiratory rate, arterial blood pressure, and heart rate were retrieved. Derangement of vital signs was defined according to predefined thresholds. 470 COVID-19 patients and 9241 controls were included. Cases were older than controls, with a median age of 79 vs 76 years in non survivors (p =  < 0.002). Gender was not associated with mortality. Overall mortality in COVID-19 hospitalized patients was 18%, ranging from 1.4% in patients below 65 years to about 30% in patients over 65 years. Heat maps analysis demonstrated that COVID-19 patients had an increased frequency in episodes of compromised respiratory rate, acute desaturation, and fever. COVID-19 epidemic profoundly affected the incidence of severe derangements in vital signs in a large academic hospital. We validated heat maps as a method to analyze the clinical stability of hospitalized patients. This method may help to improve resource allocation according to patient characteristics.

Benchmarking Cancer Centers: From Care Pathways to Integrated Practice Units

Background: Structuring cancer care into pathways can reduce variability in clinical practice and improve patient outcomes. International benchmarking can help centers with regard to development, implementation, and evaluation. A further step in the development of multidisciplinary care is to organize care in integrated practice units (IPUs), encompassing the whole pathway and relevant organizational aspects. However, research on this topic is limited. This article describes the development and results of a benchmark tool for cancer care pathways and explores IPU development in cancer centers. Methods: The benchmark tool was developed according to a 13-step benchmarking method and piloted in 7 European cancer centers. Centers provided data and site visits were performed to understand the context in which the cancer center operates and to clarify additional questions. Benchmark data were structured into pathway development and evaluation and assessed against key IPU features. Results: Benchmark results showed that most centers have formalized multidisciplinary pathways and that care teams differed in composition, and found almost 2-fold differences in mammography use efficiency. Suggestions for improvement included positioning pathways formally and structurally evaluating outcomes at a sufficiently high frequency. Based on the benchmark, 3 centers indicating that they had a breast cancer IPU were scored differently on implementation. Overall, we found that centers in Europe are in various stages of development of pathways and IPUs, ranging from an informal pathway structure to a full IPU-type of organization. Conclusions: A benchmark tool for care pathways was successfully developed and tested, and is available in an open format. Our tool allows for the assessment of pathway organization and can be used to assess the status of IPU development. Opportunities for improvement were identified regarding the organization of care pathways and the development toward IPUs. Three centers are in varying degrees of implementation and can be characterized as breast cancer IPUs. Organizing cancer care in an IPU could yield multiple performance improvements.

Hypoglycemia and hyperglycemia are risk factors for falls in the hospital population

OBJECTIVE

To determine the role of hypoglycemia, hyperglycemia or the combination of both as independent risk factors for falls in a hospital population. Secondary objectives included evaluation of other risk factors for falling and their relationships with glucose levels.

RESEARCH DESIGN AND METHODS

Retrospective cohort study over 2 years on hospitalized subjects (N = 57411) analyzing in-hospital-falls and capillary glucose values. Bivariate analysis (χ² test) and multivariate analysis (logistic regression) were performed to test for correlation of glucose values, age, sex, Charlson index, service of care, diagnosis at discharge and diabetes treatment with risk of in-hospital-falls.

RESULTS

The comparison of patients who experienced a fall (fall population) with the non-fall population suggested that: glucose determinations were significantly more frequent in the fall population (OR 3.45; CI 2.98-3.99; p < 0.0001); values of glucose below 70 mg/dl and over 200 mg/dl were significantly associated to falls during hospitalization (OR 1.76; CI 1.42-2.19; p < 0.001) as compared to glycemic values between 70 and 200 mg/dl; diabetes treatment was significantly correlated to risk of fall (OR 2.97; CI 2.54-3.49; p < 0.001); the frequency of glycemia measurements below 70 mg/dl and over 200 mg/dl in the same subject was significantly associated to falls during hospitalization (OR 1.01; CI 1.01-1.02; p < 0.001).

CONCLUSION

Hypoglycemia and hyperglycemia during hospital stays are correlated with an increased risk for falls in the hospitalized population. Presence of diabetes, use of insulin or glucose variability could potentially constitute risk factors for falls inside the hospital as well.

[HFR vs HDF-ON line: plasmatic amino acids loss evaluation]

PURPOSE

The high convection dialytic techniques, such as hemodiafiltration (HDF), can cause the loss of important molecules such as growth factors, vitamins and amino acids. Hemodiafiltration reinfusion (HFR) is an HDF on-line process, using a sipping cartridge, able to remove uremic toxins and give back a "repaired" ultra-filtrate to the patient. We aimed to establish the plasmatic amino acid levels before and after dialysis in HFR vs. HDF on-line, with scrupulous attention to branched chain amino acids (BCAA) such as isoleucine, leucine and valine. These amino acids, often present with low plasmatic levels in hemodialyzed patients, seem to be related to a picture of malnourishment.

METHODS

Eleven male patients on bicarbonate dialysis, for at least 1 yr, were evaluated (average dialytic age = 88 months, /average age = 67 yrs), with good dialytic efficiency and body mass levels, randomized in HFR or HDF on-line (filter PAN AN 69) for 1 week of treatment, respectively. The different results of each method were controlled for the same patient. Blood samples were taken before and after dialysis in each 2nd hemodialytic weekly session. Total amino acids, essential, non-essential and BCAA were determined by gas-chromatography.

RESULTS

There was no difference detected in pre-dialytic plasmatic levels of analyzed amino acids between the two groups. In post-dialysis, HDF patients demonstrated a total essential, non-essential amino acid and BCAA higher loss rate, compared to HFR patients. Post-dialysis amino acid level averages were: total amino acids in HDF 1852 +/- 302.6 micromol/L, in HFR 2395 +/- 492.8 micromol/L (p = 0.018); essential amino acids in HDF 428.8 +/- 118.2 micromol/L, in HFR 510.3 +/- 129.3 micromol/L (p = 0.022); non-essential amino acids in HDF 1176 +/- 213 micromol/L, in HFR 1546 +/- 339.2 micromol/L (p = 0.01); BCAA in HDF 242.7 +/- 83.42 micromol/L, and in HFR 286.7 +/- 89.9 micromol/L (p = 0.03).

CONCLUSIONS

Since low plasmatic BCAA levels are related to anorexia and malnourishment, the loss of these amino acids can be important in the dialytic technique choice. HFR can offer an outstanding advantage, combining a high convection treatment with medium molecule removal, without compromising physiologic molecule loss.