Hospital Resources May Be an Important Aspect of Mortality Rate among Critically Ill Patients with COVID-19: The Paradigm of Greece

For critically ill patients with coronavirus disease 2019 (COVID-19) who require intensive care unit (ICU) admission, extremely high mortality rates (even 97%) have been reported. We hypothesized that overburdened hospital resources by the extent of the pandemic rather than the disease per se might play an important role on unfavorable prognosis. We sought to determine the outcome of such patients admitted to the general ICUs of a hospital with sufficient resources. We performed a prospective observational study of adult patients with COVID-19 consecutively admitted to COVID—designated ICUs at Evangelismos Hospital, Athens, Greece. Among 50 patients, ICU and hospital mortality was 32% (16/50). Median PaO2/FiO2 was 121 mmHg (interquartile range (IQR), 86–171 mmHg) and most patients had moderate or severe acute respiratory distress syndrome (ARDS). Hospital resources may be an important aspect of mortality rates, since severely ill COVID-19 patients with moderate and severe ARDS may have understandable mortality, provided that they are admitted to general ICUs without limitations on hospital resources.

Mortality Related to Intubation in Adult General ICUs: A Systematic Review and Meta-Analysis

Context: Mortality related to intubation occurs as a result of multiple factors such as patient's condition, operator's skills, equipment use, intubation time, duration of laryngoscopy and intubation, and drugs and dosage used for endotracheal intubation (ETI). Objectives: This systematic review and meta-analysis aimed to determine mortality related to intubation and the overall intensive care unit (ICU) mortality rate in adult general ICUs. Methods: We performed a systematic review and meta-analysis on randomized clinical trials and cohort and cross-sectional research from three electronic databases with hand searching. The studies reported mortality related to intubation and the overall ICU mortality rate in adult general ICUs. Our search resulted in 28 published articles without any restriction on date and language. The systematic review and meta-analysis was performed to examine mortality related to intubation and the overall ICU mortality rate. Results: We found 7,866 articles in the literature review from the three databases based on our keywords, of which 28 studies were eligible to include in the study. We observed that mortality related to intubation and the overall ICU mortality rate in intubated patients were 1% and 30%, respectively. Conclusions: This was the first comprehensive systematic review on mortality related to intubation and the overall ICU mortality rate in adult general ICUs, which showed the current care of ETI. However, it was associated with increased complications, which may increase mortality.

P0591AKI TREATMENT WITH CVVH IN THE ICU: A FIFTEEN MONTH SINGLE-CENTER EXPERIENCE

Background and Aims AKI (Acute Kidney Injury) is a condition associated with elevated morbility and mortality. It determines prolonged hospitalization and severe long-term complications. AKI often complicates the course of patients’ stay in ICU (Intensive Care Units) sometimes requiring CRRT (Continuous Renal Replacement Therapy). Our aim was to prospectively analyze and report our experience on CRRT carried out in our hospital’s ICUs, and to compare it with guideline recommendations and with other international experiences. Method This is a single-center prospective observational study. We collected epidemiologic, clinical and technical data regarding all CRRT treatments performed in the four ICUs (two general ICUs and two cardiological ICUs) at the ASST Spedali Civili of Brescia Italy, between 02/01/2018 and 05/31/2019. AKI was defined according to KDIGO guidelines. Exclusion criteria were: age less than 16 years, chronic dialysis treatment, functioning kidney transplantation. All CRRT were provided in the CVVH (Continuous Veno-Venous Hemofiltration) mode. Results We included 146 incident patients (M: 103; 70%), mean age 71 ± 15 years. Most treatments were performed in the cardiological ICUs (58%) as opposed to the general ICUs (42%). AKI was present at the moment of admission to the ICU in 67% of patients. 53% of patients had previous CKD. The most frequent comorbidities were: hypertension (73%), diabetes (45%), ischemic heart disease (38%). The most frequent reasons for starting CVVH were: severe oliguria (88%) and fluid overload (68%). 57% of patients had stage 3 AKI. At the time of treatment initiation 55% of patients also had congestive heart failure, 52% metabolic acidosis, and 51% sepsis. 23% were recovering from heart surgery and 10% from general surgery. Mechanic ventilation was performed in 40% of patients, non-invasive ventilation in 28%. 82% of patients required vasoactive treatment. The average SOFA score was 10 ± 2,9. Technical details of CVVH prescription are reported in Fig 1. The most common vascular access was a dual lumen femoral vein catheter in 96% of cases. Citrate anticoagulation was used in 32% of treatments, heparin in 27%. Circuit coagulation was the most frequent cause for set substitution (45%). Treatments using citrate had fewer set coagulations compared to heparin (18% vs 32%). The average dialysis dose was 31,2 ml/kg/h. Median treatment duration was 7,6 days, median stay in the ICU was 14,3 days, median global hospitalization lasted 30,9 days. Mortality rate was 47% in the ICU and 64% 90 days after discharge. The most frequent causes of death were MOF (33%), septic shock (20%) and cardiogenic shock (14%). As illustrated in figure 2, multivariate analysis showed that mortality was negatively influenced by the presence of liver cirrhosis, septic shock, cardiogenic shock and rhabdomyolysis. After hospital discharge, 14 patients continued to require chronic dialysis. Conclusion Our experience shows that in patients with AKI requiring CVVH, mortality rate is negatively influenced by the presence of septic and cardiogenic shock, liver cirrhosis and rhabdomyolysis. Treatment prescription respected clinical and technical guideline recommendations, and is mostly comparable to the related international literature.

Readmissions to General ICUs in a Geographic Area of Poland Are Seemingly Associated with Better Outcomes

Background: Various factors can contribute to high mortality rates in intensive care units (ICUs). Here, we intended to define a population of patients readmitted to general ICUs in Poland and to identify independent predictors of ICU readmission. Methods: Data derived from adult ICU admissions from the Silesian region of Poland were analyzed. First-time ICU readmissions (≤30 days from ICU discharge after index admissions) were compared with first-time ICU admissions. Pre-admission and admission variables that independently influenced the need for ICU readmission were identified. Results: Among the 21,495 ICU admissions, 839 were first-time readmissions (3.9%). Patients readmitted to the ICU had lower mean APACHE II (21.2 ± 8.0 vs. 23.2 ± 8.8, p < 0.001) and TISS-28 scores (33.7 ± 7.4 vs. 35.2 ± 7.8, p < 0.001) in the initial 24 h following ICU admission, compared to first-time admissions. ICU readmissions were associated with lower mortality vs. first-time admissions (39.2% vs. 44.3%, p = 0.004). Independent predictors for ICU readmission included the admission from a surgical ward (among admission sources), chronic respiratory failure, cachexia, previous stroke, chronic neurological diseases (among co-morbidities), and multiple trauma or infection (among primary reasons for ICU admission). Conclusions: High mortality associated with first-time ICU admissions is associated with a lower mortality rate during ICU readmissions.

Aplicação do Nursing Activities Score (NAS) em diferentes tipos de UTI´s: uma revisão integrative

Objective: To compare the nursing workload measured by the Nursing Activities Score (NAS), between intensive care unit general adult ICU, and specialized surgical, cardiologic and trauma type.Methods: A literature review of the integrative type was carried out, searching the databases BDENF, LILACS, MEDLINE, and SCIELO, using the descriptors nursing, Intensive Care Unit, workload and Nursing Activities Score. They met the inclusion criteria 20 articles published in the period 2007 to 2017.Results: They show a high workload in the ICU, both in general ICUs and in all of the cited specificities, the same with a NAS score> 50.00, especially the trauma ICU, which was characterized with higher scores 72.00 and 71.3.Conclusion: In much of the research, the average number of nursing professionals calculated by the NAS is higher than the average number of professionals required by the legislation. It was observed that even in ICUs with the same specificity it was possible to perceive large differences in the mean of the NAS score, in this way, we understand that despite having the same specificity, the profile of the patient as well as that of the institution has its peculiarities requiring time to different assistance and consequently divergences in sizing. Objetivo: Comparar la carga de trabajo de enfermería medida por la Nursing Activities Score (NAS), entre la unidad de cuidados intensivos general de adultosy especializadas de quirúrgico, cardiología y trauma.Métodos: Realización de una revisión de la literatura del tipo integrativa. Búsqueda en las bases de datos BDENF, LILACS, MEDLINE, SCIELO, utilizando los descriptores enfermería, Unidad de Cuidados Intensivos, Carga de trabajo y Nursing Activities Score. Atendieron a los criterios de inclusión 20 artículos publicados en el periodo de 2007 a 2017.Resultados: Evidencian elevada carga de trabajo en UCI, tanto en UCIs general como en todas las especificidades citadas, las mismas con puntuación NAS > 50,00, destacando la UCI de trauma lo que se caracterizó con mayores marcadores 72,00 y 71,3.Conclusión: En gran parte de las investigaciones, la media de profesionales de enfermería calculada por la NAS es superior a la media de profesionales requerida por la legislación. Se observó que incluso en UCIs con la misma especificidad se perciben grandes diferencias en la media de la puntuación NAS, de esta forma, entendemos que a pesar de tener la misma especificidad, el perfil del paciente así como el de la institución tienen sus particularidades demandando tiempo de asistencia diferente y consecuentemente divergencias en el dimensionamiento. Objetivo: Comparar a carga de trabalho de enfermagem medida pelo Nursing Activities Score (NAS), entre unidade de terapia intensiva UTI geral adulto, e especializadas do tipo cirúrgica, cardiológica e trauma.Métodos: Foi realizada uma revisão de literatura do tipo integrativa, com busca nas bases de dados BDENF, LILACS, MEDLINE, e SCIELO, utilizando-se os descritores enfermagem, Unidade de Terapia Intensiva, carga de trabalho e Nursing Activities Score. Atenderam aos critérios de inclusão 20 artigos publicados no período de 2007 a 2017.Resultados: Evidenciam elevada carga de trabalho em UTI, tanto em UTIs geral quanto em todas as especificidades citadas, as mesmas com pontuação NAS > 50,00, destacando-se a UTI de trauma o que caracterizou-se com maiores escores 72,00 e 71,3.Conclusão: Em grande parte das pesquisas, a média de profissionais de enfermagem calculada pelo NAS é superior à média de profissionais requerida pela legislação. Observou-se que mesmo em UTIs com a mesma especificidade pôde-se perceber grandes diferenças na média do escore NAS, dessa forma, entendemos que apesar de possuir a mesma especificidade, o perfil do paciente assim como o da instituição tem suas particularidades demandando tempo de assistência diferente e consequentemente divergências no dimensionamento.

Family satisfaction with critical care in the UK: a multicentre cohort study

ObjectiveTo assess family satisfaction with intensive care units (ICUs) in the UK using the Family Satisfaction in the Intensive Care Unit 24-item (FS-ICU-24) questionnaire, and to investigate how characteristics of patients and their family members impact on family satisfaction.DesignProspective cohort study nested within a national clinical audit database.SettingStratified, random sample of 20 adult general ICUs participating in the Intensive Care National Audit & Research Centre Case Mix Programme.ParticipantsFamily members of patients staying at least 24 hours in ICU were recruited between May 2013 and June 2014.InterventionsConsenting family members were sent a postal questionnaire 3 weeks after the patient died or was discharged from ICU. Up to four family members were recruited per patient.Main outcome measuresFamily satisfaction was measured using the FS-ICU-24 questionnaire.Main resultsA total of 12 346 family members of 6380 patients were recruited and 7173 (58%) family members of 4615 patients returned a completed questionnaire. Overall and domain-specific family satisfaction scores were high (mean overall family satisfaction 80, satisfaction with care 83, satisfaction with information 76 and satisfaction with decision-making 73 out of 100) but varied significantly across adult general ICUs studied and by whether the patient survived ICU. For family members of ICU survivors, characteristics of both the family member (age, ethnicity, relationship to patient (next-of-kin and/or lived with patient) and visit frequency) and the patient (acute severity of illness and receipt of invasive mechanical ventilation) were significant determinants of family satisfaction, whereas, for family members of ICU non-survivors, only patient characteristics (age, acute severity of illness and duration of stay) were significant.ConclusionsOverall family satisfaction in UK adult general ICUs was high but varied significantly. Adjustment for differences in family member/patient characteristics is important to avoid falsely identifying ICUs as statistical outliers.Trial registration numberISRCTN47363549

The association between implementation of second-tier prevention practices and CLABSI incidence: A national survey

Background:Prevention of central-line–associated bloodstream infection (CLABSI) represents a complex challenge for the teams involved in device insertion and maintenance. First-tier practices for CLABSI prevention are well established.Objective:We describe second-tier prevention practices in Israeli medical-surgical ICUs and assess their association with CLABSI rates.Methods:In June 2017, an online survey assessing infection prevention practices in general ICUs was sent to all Israeli acute-care hospitals. The survey comprised 14 prevention measures supplementary to the established measures that are standard of care for CLABSI prevention. These measures fall into 2 domains: technology and implementation. The association between the number of prevention measures and CLABSI rate during the first 6 months of 2017 was assessed using Spearman’s correlation. We used negative binomial regression to calculate the incidence rate ratio (IRR) associated with the overall number of prevention measures and with each measure individually.Results:The CLABSI rates in 24 general ICUs varied between 0.0 and 17.0 per 1,000 central-line days. Greater use of preventive measures was associated with lower CLABSI rates (ρ, –0.70; P < .001). For each additional measure, the incidence of CLABSI decreased by 19% (IRR, 0.81; 95% CI, 0.73–0.89). Specific measures associated with lower rates were involvement of ward champions (IRR, 0.47; 95% CI, 0.31–0.71), auditing of insertions by infection control staff (IRR, 0.35; 95% CI, 0.19–0.64), and simulation-based training (IRR, 0.38; 95% CI, 0.22–0.64).Conclusion:Implementation of second-tier preventive practices was protective against CLABSI. Use of more practices was correlated with lower rates.