DISCORDANCE ABOUT FRAILTY DIAGNOSIS BETWEEN SURROGATES AND PHYSICIANS AND ITS RELATIONSHIP TO HOSPITAL MORTALITY IN CRITICALLY ILL OLDER ADULTS

2019 ◽  
pp. 1-4
Author(s):  
A.A. Hope ◽  
M. Ng Gong
Keyword(s):  
Older Adults ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Short Term ◽  
Clinical Frailty Scale ◽  
Observational Cohort ◽  
Critically Ill Adults ◽  
Prolonged Hospital

Abstract: The preponderance of studies on frailty assessment in critically ill adults have used the Clinical Frailty Scale (CFS) to quantify frailty and previous research suggests that surrogates were more likely to be optimistic than physicians in their CFS scores. Whether discordance between surrogates and physicians was relevant to prognosis has been underexplored. Therefore, in a prospective observational cohort of 298 critically ill older adults, we aimed 1) to describe factors related to discordance and 2) to estimate the relationship between such discordance and hospital mortality and other short-term outcomes. Discordance between surrogates and physician was present in 89/298 (29.9%) and independently associated with a higher risk of hospital mortality. Discordance was not associated with markers of intensity of treatment such as intubation, blood transfusion, incident dialysis for acute renal failure and prolonged hospital length of stay. Understanding factors relevant to discordance between physicians and surrogates may lend further insights into short-term prognosis for older adults with critical illness.

scholarly journals Impact of the Time to Initiation of Parenteral Nutrition on Patient Outcomes in Critically Ill Adults

2019 ◽  
Vol 12 ◽  
pp. 117863881985931
Author(s):  
Sunish Shah ◽  
James M Hollands ◽  
Laura Pontiggia ◽  
Angela L Bingham
Keyword(s):  
Length Of Stay ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Nutrient Intake ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Obese Patients ◽  
Time To Initiation ◽  
Critically Ill Adults ◽  
Ill Adults

Background: The optimal time to initiate parenteral nutrition (PN) in critically ill adults in whom enteral nutrition is not feasible is controversial. Objective: The objectives were to compare in-hospital mortality and hospital length of stay in patients initiated on PN within 7 days or after 7 days of poor nutrient intake. Methods: This single-center, retrospective study included critically ill adult patients who received at least 2 consecutive days of PN during hospitalization from May 2014 to July 2016. Results: The median duration of PN (interquartile range) was 8 (5-13) days. In total, 110 patients received PN within 7 days of poor nutrient intake while 49 patients received PN after 7 days of poor nutrient intake. There was no statistically significant difference in in-hospital mortality between groups (29.09% vs 18.37%, P = .1535). Patients initiated within 7 days had a significantly shorter median hospital length of stay than patients initiated after 7 days (20 days vs 27 days, P = .0013). There were 69 patients who were classified as obese. Obese patients initiated within 7 days had a significantly shorter median hospital length of stay than obese patients initiated after 7 days (17 days vs 33 days, P = .0007). Conclusions: Time to initiation of PN did not impact in-hospital mortality. However, there was an association between early initiation of PN and a shorter hospital length of stay that was most pronounced among obese patients.

Evaluation of Delirium in Critically Ill Patients Prescribed Melatonin or Ramelteon

2021 ◽  
pp. 106002802110020
Author(s):  
Natasha Romero ◽  
Kevin M. Dube ◽  
Kenneth E. Lupi ◽  
Jeremy R. DeGrado
Keyword(s):  
Clinical Outcomes ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Receptor Agonist ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Melatonin Receptor ◽  
Observational Cohort ◽  
Impaired Sleep ◽  
Retrospective Observational Cohort Study

Background: An impaired sleep-wake cycle may be one factor that affects the development of delirium in critically ill patients. Several small studies suggest that exogenous melatonin or ramelteon may decrease the incidence and/or duration of delirium. Objective: To compare the effect of prophylactic administration of melatonin, ramelteon, or no melatonin receptor agonist on the development of delirium in the intensive care unit (ICU). Methods: This was a single-center, retrospective, observational cohort study of nondelirious patients in the ICU who received melatonin, ramelteon, or no melatonin receptor agonist. The primary end point was the incidence of delirium. Secondary end points included assessments of daily level of sedation and daily utilization of antipsychotic, sedative, and opioid agents. Results: No difference was observed in the incidence of delirium among the melatonin, ramelteon, and placebo cohorts (18.7% vs 14.3% vs 13.8%; P = 0.77). A difference was observed in the rate of agitation and sedation among the 3 groups, with the greatest observed in the melatonin cohort. Additionally, there was a difference in the use of propofol, dexmedetomidine, and opioids. Overall, there was no difference in clinical outcomes, including duration of mechanical ventilation and ICU or hospital length of stay. Conclusion and Relevance: Therapy with melatonin, ramelteon, and no melatonin receptor agonist resulted in similar rates of delirium in a mixed ICU population. Despite significant differences in agitation, sedation, and medication utilization, there was no differences in the clinical outcomes evaluated.

scholarly journals 132 Physical Function Comparison of Acutely Unwell COVID-Negative Older Adults Pre-Pandemic and Through-Pandemic; “Covid-Protected”

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
S Ritchie ◽  
C Snape ◽  
N Triteos ◽  
R Vamadevan ◽  
L Olesk ◽  
...  
Keyword(s):  
Older Adults ◽  
Mortality Rate ◽  
Hospital Mortality ◽  
Physical Function ◽  
Gait Speed ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Ethical Review ◽  
Short Period ◽  
Elderly Mobility

Abstract Introduction The risk of severe morbidity after COVID-19 infection is high in older adults (Lithander et al, 2020). Subsequent responsive UK Government guidance for older adults included self-isolation during the pandemic. It is therefore hypothesised that during the pandemic older adults are inadvertently deconditioned due to iatrogenic factors such as inactivity, social isolation, hospital-avoidance and malnutrition, and present with reduced resilience to illness and lower levels of function. The OPU continued to admit COVID-negative, or recently termed “COVID-protected”, patients throughout the pandemic. Data captured prior to, and during the COVID-19 pandemic has been compared to explore the implications on older adults, and elicit whether they are protected from the consequences of the pandemic? Method Demographic and physical function data (average 6 m gait-speed, Elderly Mobility Scale) were captured pre- and through-pandemic for all patients admitted to a COVID-negative OPU ward over a one month period. Ethical review was provided through local Trust governance process. Results Pre-pandemic 2019 (n = 67, mean(±SD) age 82.7(±8.2) years, 61%, hospital length-of-stay (LOS) 7.9(±7.3) days, hospital mortality-rate 7.2%) and through-pandemic 2020 (n = 73, 83.1(±8.3) years, 59%♀, LOS 9.0(±9.1) days, hospital mortality-rate 7.5%) data were captured during July 2019 and May 2020 respectively. There were no between-group differences in age [t(−.313) = 138, p = 0.755], gender [X2, 1 df, p = 0.782], LOS [t(0.78) = 134, p = 0.44], or hospital mortality-rate [X2 1 df, p = 0.96]. Through-pandemic patients had a significantly slower 6 m gait-speed (0.11(±0.05) m.s-1) than pre-pandemic (0.16(±0.24) m.s-1); [t(2.74) = 93, p = 0.007] and lower median (IQR) Elderly Mobility Scale (4(6 IQR) vs 9 (12 IQR) [u = 866, p = 0.015]). Conclusion Our data indicates this relatively short period of self-isolation might have significant implications on the physical function of older adults. The likely mechanism is iatrogenic deconditioning. Critical Public Health and policy responses are required to mitigate these unforeseen risks by deploying prehabilitative counter-measures and accurately targeted hospital and community rehabilitation.

Frailty in Critical Care: Examining Implications for Clinical Practices

2018 ◽  
Vol 38 (3) ◽  
pp. 29-35 ◽  
Author(s):  
Jennifer A. Gibson ◽  
Sarah Crowe
Keyword(s):  
Older Adults ◽  
Critical Care ◽  
Functional Decline ◽  
Hospital Length ◽  
Adverse Outcomes ◽  
Hospital Length Of Stay ◽  
Clinical State ◽  
Clinical Practices ◽  
Delivery Of Care ◽  
Prolonged Hospital

Frailty is an aging-related, multisystem clinical state characterized by loss of physiological reserves and diminished capacity to withstand exposure to stressors. Frailty increases the risk of serious adverse outcomes, compared with that of nonfrail people of the same age. Adverse outcomes can be severe and may include procedural complications, delirium, significant functional decline and disability, prolonged hospital length of stay, extended recovery periods, and death. As older adults make up a continually growing proportion of hospitalized patients, critical care nurses need to understand how to recognize frailty and be familiar with related clinical practice implications. Such knowledge underpins effective organization and delivery of care strategies aimed at minimizing harm and maximizing positive outcomes for frail older adults. Drawing from recent literature, this article explores frailty and critical illness by discussing 2 dominant models of the concept. Using a clinical case study, links between frailty and critical care nursing practices are highlighted and clinical considerations are explored.

scholarly journals Severe Acute Kidney Injury in Critically Ill Patients with COVID-19 Admitted to ICU: Incidence, Risk Factors, and Outcomes

2021 ◽  
Vol 10 (6) ◽  
pp. 1217
Author(s):  
Muriel Ghosn ◽  
Nizar Attallah ◽  
Mohamed Badr ◽  
Khaled Abdallah ◽  
Bruno De Oliveira ◽  
...  
Keyword(s):  
Risk Factors ◽  
Acute Kidney Injury ◽  
Respiratory Failure ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Incidence Risk

Background: Critically ill patients with COVID-19 are prone to develop severe acute kidney injury (AKI), defined as KDIGO (Kidney Disease Improving Global Outcomes) stages 2 or 3. However, data are limited in these patients. We aimed to report the incidence, risk factors, and prognostic impact of severe AKI in critically ill patients with COVID-19 admitted to the intensive care unit (ICU) for acute respiratory failure. Methods: A retrospective monocenter study including adult patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection admitted to the ICU for acute respiratory failure. The primary outcome was to identify the incidence and risk factors associated with severe AKI (KDIGO stages 2 or 3). Results: Overall, 110 COVID-19 patients were admitted. Among them, 77 (70%) required invasive mechanical ventilation (IMV), 66 (60%) received vasopressor support, and 9 (8.2%) needed extracorporeal membrane oxygenation (ECMO). Severe AKI occurred in 50 patients (45.4%). In multivariable logistic regression analysis, severe AKI was independently associated with age (odds ratio (OR) = 1.08 (95% CI (confidence interval): 1.03–1.14), p = 0.003), IMV (OR = 33.44 (95% CI: 2.20–507.77), p = 0.011), creatinine level on admission (OR = 1.04 (95% CI: 1.008–1.065), p = 0.012), and ECMO (OR = 11.42 (95% CI: 1.95–66.70), p = 0.007). Inflammatory (interleukin-6, C-reactive protein, and ferritin) or thrombotic (D-dimer and fibrinogen) markers were not associated with severe AKI after adjustment for potential confounders. Severe AKI was independently associated with hospital mortality (OR = 29.73 (95% CI: 4.10–215.77), p = 0.001) and longer hospital length of stay (subhazard ratio = 0.26 (95% CI: 0.14–0.51), p < 0.001). At the time of hospital discharge, 74.1% of patients with severe AKI who were discharged alive from the hospital recovered normal or baseline renal function. Conclusion: Severe AKI was common in critically ill patients with COVID-19 and was not associated with inflammatory or thrombotic markers. Severe AKI was an independent risk factor of hospital mortality and hospital length of stay, and it should be rapidly recognized during SARS-CoV-2 infection.

scholarly journals Bariatric Procedures in Older Adults in the United States: Analysis of a Multicenter Database

Geriatrics ◽  
2019 ◽  
Vol 4 (2) ◽  
pp. 32 ◽  
Author(s):  
Mendiratta ◽  
Dayama ◽  
Azhar ◽  
Prodhan ◽  
Wei
Keyword(s):  
Risk Factors ◽  
Older Adults ◽  
Hospital Mortality ◽  
Clinical Characteristics ◽  
Skilled Nursing Facility ◽  
The United States ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Factors Associated ◽  
Choice Of Procedure

Background: Bariatric procedures help reduce obesity-related comorbidities and thus improve survival. Clinical characteristics and outcomes after bariatric procedures in older adults were investigated. Methods: A multi-institutional Nationwide Inpatient Sample (NIS) database was queried from years 2005 through 2012. Older adults >60 years of age with procedure codes for bariatric procedures and a diagnosis of obesity/morbid obesity were selected to compare clinical characteristics/outcomes between those undergoing closed versus open procedures and identify risk factors associated with in-hospital mortality and increased hospital length of stay (LOS). Results: Over the study period, 79,122 bariatric procedures were performed. Those undergoing open procedures compared to closed procedures had a higher in-hospital mortality (0.8% vs. 0.2%) and a longer hospital LOS (4.8 days vs. 2.2 days). Risk factors significantly associated with in-hospital mortality were open procedures, the Western region, and the Elixhauser comorbidity index. Risk factors associated with increased LOS were Medicaid insurance type, an open procedure, a higher Elixhauser comorbidity score, a required skilled nursing facility (SNF) discharge, and died in hospital. Conclusion: Closed bariatric procedures are increasingly being preferred in older adults, with a four-fold lower mortality compared to open procedures. Besides choice of procedure, the presence of specific comorbidities is associated with increased mortality in older adults.

scholarly journals The efficacy and safety of prokinetics in critically ill adults receiving gastric feeding tubes: A systematic review and meta-analysis

PLoS ONE ◽  
2021 ◽  
Vol 16 (1) ◽  
pp. e0245317
Author(s):  
Rong Peng ◽  
Hailong Li ◽  
Lijun Yang ◽  
Linan Zeng ◽  
Qiusha Yi ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Critically Ill ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Efficacy And Safety ◽  
Feeding Tubes ◽  
Gastric Feeding ◽  
Critically Ill Adults ◽  
Ill Adults

Background Intolerance to gastric feeding tubes is common among critically ill adults and may increase morbidity. Administration of prokinetics in the ICU is common. However, the efficacy and safety of prokinetics are unclear in critically ill adults with gastric feeding tubes. We conducted a systematic review to determine the efficacy and safety of prokinetics for improving gastric feeding tube tolerance in critically ill adults. Methods Randomized controlled trials (RCTs) were identified by systematically searching the Medline, Cochrane and Embase databases. Two independent reviewers extracted the relevant data and assessed the quality of the studies. We calculated pooled relative risks (RRs) for dichotomous outcomes and the mean differences (MDs) for continuous outcomes with the corresponding 95% confidence intervals (CIs). We assessed the risk of bias using the Cochrane risk-of-bias tool and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to rate the quality of the evidence. Results Fifteen RCTs met the inclusion criteria. A total of 10 RCTs involving 846 participants were eligible for the quantitative analysis. Most studies (10 of 13, 76.92%) showed that prokinetics had beneficial effects on feeding intolerance in critically ill adults. In critically ill adults receiving gastric feeding, prokinetic agents may reduce the ICU length of stay (MD -2.03, 95% CI -3.96, -0.10; P = 0.04; low certainty) and the hospital length of stay (MD -3.21, 95% CI -5.35, -1.06; P = 0.003; low certainty). However, prokinetics failed to improve the outcomes of reported adverse events and all-cause mortality. Conclusion As a class of drugs, prokinetics may improve tolerance to gastric feeding to some extent in critically ill adults. However, the certainty of the evidence suggesting that prokinetics reduce the ICU or hospital length of stay is low. Prokinetics did not significantly decrease the risks of reported adverse events or all-cause mortality among critically ill adults.

scholarly journals Diarrhoea: interventions, consequences and epidemiology in the intensive care unit (DICE-ICU): a protocol for a prospective multicentre cohort study

BMJ Open ◽  
2019 ◽  
Vol 9 (6) ◽  
pp. e028237 ◽  
Author(s):  
Joanna C Dionne ◽  
Kristen Sullivan ◽  
Lawrence Mbuagbaw ◽  
Alyson Takaoka ◽  
Erick Huaileigh Duan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intensive Care Unit ◽  
Cohort Study ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Primary Outcome ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Secondary Outcomes

IntroductionDiarrhoea is a frequent concern in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, increased length of ICU stay, skin breakdown and renal dysfunction. However, its prevalence, aetiology and prognosis in the critically ill have been poorly studied. The primary objectives of this study are to determine the incidence, risk factors and consequences of diarrhoea in critically ill adults. The secondary objectives are to estimate the incidence ofClostridium difficile-associated diarrhoea (CDAD) in ICU patients and to validate the Bristol Stool Chart and Bliss Stool Classification System characterising bowel movements in the ICU. Our primary outcome is the incidence of diarrhoea . Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay.Methods and analysisThis international prospective cohort study will enrol patients over 10 weeks in 12 ICUs in Canada, the USA, Poland and Saudi Arabia. We will include all patients 18 years of age and older who are admitted to the ICU for at least 24 hours and follow them daily until ICU discharge. Our primary outcome is the incidence of diarrhoea based on the WHO definition, during the ICU stay. Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. We will use logistic regression to identify factors associated with diarrhoea (as defined using WHO criteria) and the kappa statistic to measure agreement on diarrhoea rates between the WHO definition and the Bristol Stool Chart and Bliss Stool Classification System.Ethics and disseminationThe protocol has been approved by the research ethics board of all participating centres. The diarrhoea interventions, consequences and epidemiology in the intensive care unit (DICE-ICU) study will generate evidence about diarrhoea and its frequency, predisposing factors and consequences, to inform critical care practice and future research.Lay summaryDiarrhoea is a frequent clinical problem for hospitalised patients including those who are critically ill in the ICU. Diarrhoea can cause complications such as skin damage, dehydration and kidney problems. It is not clear how common diarrhoea is in the ICU, the factors that cause it or the best way for clinicians to assess it. The DICE-ICU study is an international prospective observational study to examine the frequency, risk factors and outcomes of diarrhoea during critical illness.

scholarly journals Safety of delivering bronchial thermoplasty in two treatment sessions

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Kavya Koshy ◽  
Joy Sha ◽  
Kim Bennetts ◽  
David Langton
Keyword(s):  
Severe Asthma ◽  
Left Lung ◽  
Complete Recovery ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Treatment Schedule ◽  
Short Term ◽  
Bronchial Thermoplasty ◽  
The Right ◽  
Prolonged Hospital

Abstract Background Bronchial thermoplasty (BT) is a novel endoscopic therapy for severe asthma. Traditionally it is performed in three separate treatment sessions, targeting different portions of the lung, and each requires an anaesthetic and hospital admission. Compression of treatment into 2 sessions would present a more convenient alternative for patients. In this prospective observational study, the safety of compressing BT into two treatment sessions was compared with the traditional 3 treatment approach. Methods Sixteen patients meeting ERS/ATS criteria for severe asthma consented to participate in an accelerated treatment schedule (ABT), which treated the whole left lung followed by the right lung four weeks later. The short-term outcomes of these patients were compared with 37 patients treated with conventional BT scheduling (CBT). The outcome measures used to assess safety were (1) the requirement to remain in hospital beyond the electively planned 24-h admission and (2) the need for re-admission for any cause within of 30 days of treatment. Results The total number of radiofrequency activations delivered in the ABT group was similar to CBT (187 ± 21 vs 176 ± 40, p = 0.326). With ABT, 11 in 31 admissions (37.9%) required prolonged admission due to wheezing, compared to 5.4% with CBT (p = 0.0025). The mean hospital length of stay with ABT was 1.8 ± 1.3 days, compared to 1.1 ± 0.4 days (p < 0.001). ICU monitoring was required on 5 occasions with ABT (16.1%), compared to 0.9% with CBT (p = 0.002). Subgroup analysis demonstrated that females were more likely to require prolonged admission (OR 11.6, p = 0.0025). The 30-day hospital readmission rate was similar for both groups (6.4% vs 5.4%, p = 0.67). All patients made a complete recovery after treatment with similar outcomes at the 6-month follow-up reassessment. Conclusion This study demonstrates that ABT results in greater short-term deterioration in lung function associated with a greater risk of prolonged hospital and ICU stay, predominantly affecting females. Therefore, in females, these risks need to be balanced against the convenience of fewer treatment sessions. In males, it may be an advantage to compress treatment.

scholarly journals Ethnicity and outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort study

BMJ Open ◽  
2021 ◽  
Vol 11 (1) ◽  
pp. e042140
Author(s):  
Vanessa J Apea ◽  
Yize I Wan ◽  
Rageshri Dhairyawan ◽  
Zudin A Puthucheary ◽  
Rupert M Pearse ◽  
...  
Keyword(s):  
Premature Death ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Organ Support ◽  
Invasive Ventilation ◽  
Black Patients ◽  
Hospitalised Patients ◽  
Observational Cohort ◽  
The Impact ◽  
To Receive

ObjectiveTo describe outcomes within different ethnic groups of a cohort of hospitalised patients with confirmed COVID-19 infection. To quantify and describe the impact of a number of prognostic factors, including frailty and inflammatory markers.SettingFive acute National Health Service Hospitals in east London.DesignProspectively defined observational study using registry data.Participants1737 patients aged 16 years or over admitted to hospital with confirmed COVID-19 infection between 1 January and 13 May 2020.Main outcome measuresThe primary outcome was 30-day mortality from time of first hospital admission with COVID-19 diagnosis during or prior to admission. Secondary outcomes were 90-day mortality, intensive care unit (ICU) admission, ICU and hospital length of stay and type and duration of organ support. Multivariable survival analyses were adjusted for potential confounders.Results1737 were included in our analysis of whom 511 had died by day 30 (29%). 538 (31%) were from Asian, 340 (20%) black and 707 (40%) white backgrounds. Compared with white patients, those from minority ethnic backgrounds were younger, with differing comorbidity profiles and less frailty. Asian and black patients were more likely to be admitted to ICU and to receive invasive ventilation (OR 1.54, (95% CI 1.06 to 2.23); p=0.023 and OR 1.80 (95% CI 1.20 to 2.71); p=0.005, respectively). After adjustment for age and sex, patients from Asian (HR 1.49 (95% CI 1.19 to 1.86); p<0.001) and black (HR 1.30 (95% CI 1.02 to 1.65); p=0.036) backgrounds were more likely to die. These findings persisted across a range of risk factor-adjusted analyses accounting for major comorbidities, obesity, smoking, frailty and ABO blood group.ConclusionsPatients from Asian and black backgrounds had higher mortality from COVID-19 infection despite controlling for all previously identified confounders and frailty. Higher rates of invasive ventilation indicate greater acute disease severity. Our analyses suggest that patients of Asian and black backgrounds suffered disproportionate rates of premature death from COVID-19.

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