A Randomized Trial of Primary Intensive Care to Reduce Hospital Admissions in Patients with High Utilization of Inpatient Services

Background: Cocaine-induced chest pain (CICP) is reported in 40% of patients using cocaine and is associated with frequent emergency room visits and hospital admissions. Hypothesis: Coronary computed tomographic angiography (CCTA) has better outcomes than standard-of-care (SOC) for the evaluation of patients with CICP. Method: CICP patients were randomized to CCTA protocol or SOC. The primary outcome of the study was a composite of recurrent emergency room visits and hospital admissions. Secondary outcomes included length of stay, major adverse cardiovascular events and all-cause mortality. Results: The study population consisted of 202 patients with CICP (CCTA=23 and SOC=179). As compared to SOC, the number of emergency room visits in the CCTA group were lower at 30 days (1.04±0.1 vs. 1.24±0.5, p=0.012) and 1 year (2.43±0.9 vs. 2.61±2.1, p=0.008), but not at 3 years (5.04±3.3 vs. 4.87±1, p=0.112) findings that were independent of CCTA results. Mean admission rates for the CCTA group were slightly but not significantly lower than the SOC group at 30 days (0.91±0.1 vs.1.10±0.2 p=0.438) and 1 year (1.52±0.3 vs. 1.82±0.3 p=0.187), but not at 3 years (3.22±0.6 vs. 2.95±0.5, p=0.111). Hospital length of stay was also lower in CCTA patients than in SOC patients (2.61±0.5 vs. 3.34 ± 0.5 p<0.001). After 3 year follow-up, there was 1 major adverse cardiovascular event in the CCTA group compared to 22 in the SOC group (p=0.024). No patient died in the CCTA while 3 patients died from any cause in the SOC group (p=0.776) after 3 years of follow-up. Conclusion: In this prospective randomized trial, CCTA reduced near and intermediate-term but not long-term rates of emergency room visits and hospitalizations. When compared to SOC, the use of CCTA was associated with a reduction of major adverse cardiovascular events. Larger randomized controlled trials to further assess the efficacy of a CCTA-based strategy for CICP appear warranted.

Download Full-text

The efficacy and safety of rifaximin-α: a 2-year observational study of overt hepatic encephalopathy

Therapeutic Advances in Gastroenterology ◽

10.1177/1756284819858256 ◽

2019 ◽

Vol 12 ◽

pp. 175628481985825 ◽

Cited By ~ 1

Author(s):

Rosalie C. Oey ◽

Lennart E.M. Buck ◽

Nicole S. Erler ◽

Henk R. van Buuren ◽

Robert A. de Man

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Hepatic Encephalopathy ◽

Adverse Events ◽

Bacterial Infections ◽

Hospital Admissions ◽

Emergency Department Visits ◽

Interquartile Range ◽

Overt Hepatic Encephalopathy ◽

Bed Days

Background: After 5 years since the registration of rifaximin-α as a secondary prophylaxis for overt hepatic encephalopathy (HE) in the Netherlands, we aimed to evaluate the use of hospital resources and safety of rifaximin-α treatment in a real-world setting. Methods: We carried out prospective identification of all patients using rifaximin-α for overt HE. We assessed hospital resource use, bacterial infections, and adverse events during 6-month episodes before and after rifaximin-α initiation. Results: During 26 months we included 127 patients [71.7% male; median age 60.8 years (interquartile range: 56.2–66.1); median model for end-stage liver disease (MELD) score 15.0 (interquartile range: 12.1–20.4); 98% using lactulose treatment]. When comparing the first 6 months after rifaximin-α initiation with the prior 6 months, HE-related hospital admissions decreased (0.86 to 0.41 admissions/patient; p < 0.001), as well as the mean length of stay (8.85 to 3.79 bed days/admission; p < 0.001). No significant differences were found regarding HE-related intensive care unit admissions (0.09 to 0.06 admission/patient; p = 0.253), stay on the intensive care unit (0.43 to 0.57 bed days/admission; p = 0.661), emergency department visits (0.66 to 0.51 visits/patient; p = 0.220), outpatient clinic visits (2.49 to 3.30 bed visits/patient; p = 0.240), or bacterial infections (0.41 to 0.35 infections/patient; p = 0.523). Adverse events were recorded in 2.4% of patients. Conclusions: The addition of rifaximin-α to lactulose treatment was associated with a significant reduction in the number and length of HE-related hospitalizations for overt HE. Rifaximin-α treatment was well tolerated.

Download Full-text

A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care

Implementation Science ◽

10.1186/s13012-015-0285-2 ◽

2015 ◽

Vol 10 (1) ◽

Cited By ~ 4

Author(s):

Maartje L. G. de Vos ◽

Sabine N. van der Veer ◽

Bram Wouterse ◽

Wilco C. Graafmans ◽

Niels Peek ◽

...

Keyword(s):

Intensive Care ◽

Randomized Trial ◽

Cluster Randomized Trial ◽

Feedback Strategy ◽

Cluster Randomized

Download Full-text

Prototype of a computerized scale for the active search for potential organ donors

Revista Latino-Americana de Enfermagem ◽

10.1590/1518-8345.1936.2930 ◽

2017 ◽

Vol 25 (0) ◽

Cited By ~ 1

Author(s):

Érika Fernanda dos Santos Bezerra Ludwig ◽

Marta Cristiane Alves Pereira ◽

Yolanda Dora Évora Martinez ◽

Karina Dal Sasso Mendes ◽

Mariana Angela Rossaneis

Keyword(s):

Intensive Care ◽

Medical Records ◽

Hospital Admissions ◽

Tertiary Hospital ◽

Wilcoxon Test ◽

Organ Donors ◽

Cardiorespiratory Arrest ◽

Active Search ◽

Death Cases ◽

Severity Indexes

ABSTRACT Objective: to develop a prototype of a computerized scale for the active search for potential organ and tissue donors. Method: methodological study, with the analysis of 377 electronic medical records of patients who died due to encephalic death or cardiorespiratory arrest in the intensive care units of a tertiary hospital. Among the deaths due to cardiorespiratory arrest, the study aimed to identify factors indicating underreported encephalic death cases. The Acute Physiology and Chronic Health Evaluation II and Sepsis Related Organ Failure Assessment severity indexes were applied in the protocols. Based on this, a scale was built and sent to five experts for assessment of the scale content, and subsequently, it was computerized by using a prototyping model. Results: 34 underreported encephalic death cases were identified in the medical records of patients with cardiorespiratory arrest. Statistically significant differences were found in the Wilcoxon test between the scores of hospital admissions in the intensive care unit and the opening of the encephalic death protocol for both severity indexes. Conclusion: the prototype was effective for identifying potential organ donors, as well as for the identification of the degree of organ dysfunction in patients with encephalic death.

Download Full-text

Validation of automated sepsis surveillance based on the Sepsis-3 clinical criteria against physician record review in a general hospital population: observational study using electronic health records data

BMJ Quality & Safety ◽

10.1136/bmjqs-2019-010123 ◽

2020 ◽

Vol 29 (9) ◽

pp. 735-745 ◽

Cited By ~ 4

Author(s):

John Karlsson Valik ◽

Logan Ward ◽

Hideyuki Tanushi ◽

Kajsa Müllersdorf ◽

Anders Ternhag ◽

...

Keyword(s):

Intensive Care ◽

Medical Record ◽

Predictive Value ◽

Hospital Admissions ◽

Medical Record Review ◽

Suspected Infection ◽

Clinical Criteria ◽

Physician Review ◽

Electronic Health ◽

Record Review

BackgroundSurveillance of sepsis incidence is important for directing resources and evaluating quality-of-care interventions. The aim was to develop and validate a fully-automated Sepsis-3 based surveillance system in non-intensive care wards using electronic health record (EHR) data, and demonstrate utility by determining the burden of hospital-onset sepsis and variations between wards.MethodsA rule-based algorithm was developed using EHR data from a cohort of all adult patients admitted at an academic centre between July 2012 and December 2013. Time in intensive care units was censored. To validate algorithm performance, a stratified random sample of 1000 hospital admissions (674 with and 326 without suspected infection) was classified according to the Sepsis-3 clinical criteria (suspected infection defined as having any culture taken and at least two doses of antimicrobials administered, and an increase in Sequential Organ Failure Assessment (SOFA) score by >2 points) and the likelihood of infection by physician medical record review.ResultsIn total 82 653 hospital admissions were included. The Sepsis-3 clinical criteria determined by physician review were met in 343 of 1000 episodes. Among them, 313 (91%) had possible, probable or definite infection. Based on this reference, the algorithm achieved sensitivity 0.887 (95% CI: 0.799 to 0.964), specificity 0.985 (95% CI: 0.978 to 0.991), positive predictive value 0.881 (95% CI: 0.833 to 0.926) and negative predictive value 0.986 (95% CI: 0.973 to 0.996). When applied to the total cohort taking into account the sampling proportions of those with and without suspected infection, the algorithm identified 8599 (10.4%) sepsis episodes. The burden of hospital-onset sepsis (>48 hour after admission) and related in-hospital mortality varied between wards.ConclusionsA fully-automated Sepsis-3 based surveillance algorithm using EHR data performed well compared with physician medical record review in non-intensive care wards, and exposed variations in hospital-onset sepsis incidence between wards.

Download Full-text