Models for Assessing Strategies for Improving Hospital Capacity for Handling Patients during a Pandemic

Objective: The aim of this study was to investigate the performance of key hospital units associated with emergency care of both routine emergency and pandemic (COVID-19) patients under capacity enhancing strategies. Methods: This investigation was conducted using whole-hospital, resource-constrained, patient-based, stochastic, discrete-event simulation models of a generic 200-bed urban U.S. tertiary hospital serving routine emergency and COVID-19 patients. Systematically designed numerical experiments were conducted to provide generalizable insights into how hospital functionality may be affected by the care of COVID-19 pandemic patients along specially designated care paths under changing pandemic situations from getting ready to turning all of its resources to pandemic care. Results: Several insights are presented. For example, each day of reduction in average ICU length of stay increases intensive care unit patient throughput by up to 24% for high COVID-19 daily patient arrival levels. The potential of five specific interventions and two critical shifts in care strategies to significantly increase hospital capacity is described. Conclusions: These estimates enable hospitals to repurpose space, modify operations, implement crisis standards of care, prepare to collaborate with other health care facilities, or request external support, increasing the likelihood that arriving patients will find an open staffed bed when one is needed.

Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy

Background: The clinical benefit from endovascular therapy (EVT) for patients with acute ischemic stroke is time-dependent. We tested the hypothesis that team prenotification results in faster procedure times prior to initiation of EVT.Methods: We analyzed data from our prospective database (01/2016–02/2018) including all patients with acute ischemic stroke who were evaluated for EVT at our comprehensive stroke center. We established a standardized algorithm (EVT-Call) in 06/2017 to prenotify team members (interventional neuroradiologist, neurologist, anesthesiologist, CT and angiography technicians) about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before (–EVT-Call) and after (+EVT-Call) implementation of the EVT-Call.Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65–81], NIHSS score 17 [12–22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call). Median (IQR) door-to-image time (18 min [14–22] vs. 10 min [7–13]; p < 0.001), image-to-groin time (54 min [43.5–69.25] vs. 47 min [38.3–58.75]; p = 0.042) and door-to-groin time (74 min [58–86.5] vs. 60 min [49.3–71]; p < 0.001) were reduced after implementation of the EVT-Call.Conclusions: Team prenotification results in faster patient assessment and initiation of EVT in patients with acute ischemic stroke. Its impact on functional outcome needs to be determined.

Mitochondrial dysfunction in trauma-related coagulopathy – Is there causality? – Study protocol for a prospective observational study

Hemorrhage control often poses a great challenge for clinicians due to trauma-induced coagulopathy (TIC). The pathogenesis of TIC is not completely revealed; however, growing evidence attributes a central role to altered platelet biology. The activation of thrombocytes and subsequent clot formation are highly energetic processes being tied to mitochondrial activity, and the inhibition of the electron transport chain (ETC) impedes on thrombogenesis, suggesting the potential role of mitochondria in TIC. Our present study protocol provides a guide to quantitatively characterize the derangements of mitochondrial functions in TIC. One hundred eleven severely injured (Injury Severity Score ≥16), bleeding trauma patients with an age of 18 or greater will be included in this prospective observational study. Patients receiving oral antiplatelet agents including cyclooxygenase-1 or adenosine diphosphate receptor inhibitors (aspirin, clopidogrel, prasugrel, and ticagrelor) will be excluded from the final analysis. Hemorrhage will be confirmed and assessed with computer tomography. Conventional laboratory markers of hemostasis such as prothrombin time and international normalized ratio (INR) will be measured and rotational thromboelastometry (ROTEM) will be performed directly upon patient arrival. Platelets will be isolated from venous blood samples and subjected to high-resolution fluororespirometry (Oxygraph-2k, Oroboros Instruments, Innsbruck, Austria) to evaluate the efficacy of mitochondrial respiration. Oxidative phosphorylation (OxPhos), coupling of the ETC, mitochondrial superoxide formation, mitochondrial membrane potential changes and extramitochondrial Ca2+-movement will be recorded. The association between OxPhos capacity of platelet mitochondria and numerical parameters of ROTEM aggregometry will constitute our primary outcome. The relation between OxPhos capacity and results of viscoelastic assays and conventional markers of hemostasis will serve as secondary outcomes. The association of the OxPhos capacity of platelet mitochondria upon patient arrival to the need for massive blood transfusion (MBT) and 24-hour mortality will constitute our tertiary outcomes. Mitochondrial dysfunction and its importance in TIC in are yet to be assessed for the deeper understanding of this common, life-threatening condition. Disclosure of mitochondria-mediated processes in thrombocytes may reveal new therapeutic targets in the management of hemorrhaging trauma patients, thereby leading to a reduction of potentially preventable mortality. The present protocol was registered to ClinicalTrials.gov on 12 August 2021, under the reference number NCT05004844.

Abstract 10336: ECPR 2 : Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering out-of-hospital cardiac arrest (OHCA), though limited data exists regarding detailed best practices for the complex process of initiating ECPR following OHCA. Hypothesis: Expert consensus using a modified Delphi process can systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. Methods: We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale. Results: Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and four primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 216 items. The panel ultimately reached consensus on 95 items: Prior to Patient Arrival (8 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (17), and Post-Cannulation (26). Conclusion: We present a list of essential items for initiation of ECPR following adult non-traumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings can benefit centers currently performing ECPR for OHCA in quality assurance and performance improvement, and can serve as a template for new ECPR programs to follow.

Role of Point of Care Ultra Sound (POCUS) in Assessment of Fluid Resuscitation in Septic Patients

Background: Initial fluid resuscitation in sepsis must be guided by clinical judgment based on ongoing reevaluation of the hemodynamic status (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output) and ultrasound measurements (stroke volume, cardiac output, lung ultrasound and inferior vena cava diameter) as positive fluid balance is harmful. Methods: Adults Patients (≥ 18 years old) with symptoms or signs of tissue hypoperfusion (Sequential organ failure assessment score SOFA≥ 2) are included. Patients with elevated intra-abdominal pressure (as, ascites, pregnancy), Recent abdominal operation, cannot lie flat, Patient on mechanical ventilation and patients with valvular heart disease were excluded. IVC CI, SV, COP and B mean score were measured on patient arrival and after every 10 ml/kg isotonic saline over the first hour of patient arrival. Thereafter, patients were divided into two groups high caval index and low caval index according to inferior vena cava collapsibility index. Results: Among our 50 patients,38% of patients were with high caval index and 62% have low caval index. Conclusion: POCUS has additive value in guiding of fluid resuscitation in sepsis in order to avoid fluid overload and to identify proper timing of vasopressor use.

Comparison of the Clinical Process and Outcomes in Patients after Coronavirus Infection 2019 Outbreak

Background and Objectives: The coronavirus infection 2019 (COVID-19) pandemic has affected emergency department (ED) management. Its viral transmission necessitates the use of isolation rooms and personal protective equipment for treating suspected patients, such as those with fever. This delays the time until the first encounter with the patients, thereby increasing the length of stay (LOS) in the ED. We aimed to compare delays in the ED LOS and clinical processes between the COVID-19 period and pre-COVID-19 period. Moreover, we intended to evaluate if the aforementioned delay affected patient outcomes. Materials and Methods: We conducted a single-center, retrospective study in Korea. Patients with fever were compared between the “COVID-19 period” from March 2020 to August 2020 and the “pre-COVID-19 period” from March 2019 to September 2019. We compared the overall ED LOS and individual time variable, including initial diagnostic tests (laboratory tests, radiography), specific diagnostic test (computed tomography), and treatment processes (antibiotics). A logistic regression analysis was conducted to identify the association between hospital admission and patient data. Results: We enrolled 931 and 749 patients during pre- and COVID-19 periods, respectively. Patients with fever remained in the ED for a longer duration during the COVID-19 period (pre-COVID-19:207.7 ± 102.7 min vs. during COVID-19: 223.5 ± 119.4 min, p = 0.004). The total time for performing laboratory tests and radiography displayed significant differences between the two periods, particularly from the time of patient arrival in the ED to the time of issuing the order. The time until antibiotic administration was delayed in the COVID-19 period (pre-COVID-19:195.8 ± 103.3 min vs. during COVID-19: 216.9 ± 108.4 min, p = 0.003). The logistic regression analysis for hospital admission identified ED LOS as an independent factor in both periods. Conclusions: The delay until encountering patients with fever resulted in longer ED LOS during the COVID-19 period; however, it possibly did not increase the hospital admission rates.

Door-to-Furosemide time effects on in-hospital mortality and length of stay in acute heart failure patients

Background Acute heart failure (AHF) is a common cause of hospitalization and mortality. Time-to-therapy concept may help improve in-hospital outcomes. Objective To evaluate In-hospital outcomes after receiving early versus delayed furosemide injection among AHF patients. Method Retrospective single-center cohort study included patients who were admitted with AHF through ED during 1 July 2017 to 31 Dec 2019. Door-to-furosemide (D2F) time was defined as the time from patient arrival at the ED to the first intravenous furosemide injection within 24 hours. Patients with a D2F time ≤60 min were classified as the early treatment group. Primary outcome was in-hospital mortality and secondary outcomes were in-hospital morbidities. Adjusted odd ratio and the 95% confidence interval (CI) were represented using multiple logistic regression adjusted for age, sex, weight, furosemide dose, and baseline serum creatinine. Results Among 820 enrolled AHF patients, the median D2F time was 80.5 min (interquartile range: 42 to 187 min). of those 324 (39%) patients were categorized into early D2F time group. The rate of total in-hospital death was 4.9% and did not differ between groups (3.1% vs. 6%, early vs delayed D2F group; p=0.067). In multivariate analysis, early treatment is not significantly associated with lower in-hospital mortality (odd ratio: 0.57; 95% CI: 0.27–1.23; p=0.152) as well as secondary endpoints. Conclusions In this small single-center study, early treatment with furosemide was uncommon. Less than half of admitted patients were received furosemide within 1 hour. In-hospital mortality was double in delayed group but was not statistically significant. FUNDunding Acknowledgement Type of funding sources: None.

A Record-based Analysis of Profile, Pattern and Outcomes of Geriatric Fractures in a Tertiary CareHospital, Chandigarh

Introduction: Older people with diseased conditions are more prone to fracture irrespective of gender. Osteoporosis is the most common cause of elderly fractures. Objectives: 1) To ascertain the profile and pattern of geriatric fracture cases reporting a tertiary care institution, 2) To ascertain the extent of mortality and complications in geriatric fracture cases, and 3) To ascertain the functional outcomes of geriatric fracture cases discharged from the tertiary care institute. Methodology: A list of geriatric fracture inpatients of an institution was made for 2014 - 2018. The data on the profile of patients, type of fracture, treatment received, the lag time between the reporting and the surgery, comorbidities, past medical history, cause/ place of fracture, length of stay, and status at the time of the phone-based interview were analysed through SPSS software. Results: The highest range of the age for fracture occurrence was 60-70 years. Female patients were more than the male ones. Femur fracture was the most common. The most common direct cause of the fracture was fall (indoor). Open reduction, internal fixation and arthroplasty were the commonest treatment performed. The lag time between the patient arrival to the health care and surgery was 0-5 days. The highest length of stay by the patients in the hospital was 0-10 days. Conclusion: The possible direct causes of the fracture reported in the study were falls, roadside accidents, trauma etc.

COVID-19 Critical Care Simulations: An International Cross-Sectional Survey

Objective: To describe the utility and patterns of COVID-19 simulation scenarios across different international healthcare centers.Methods: This is a cross-sectional, international survey for multiple simulation centers team members, including team-leaders and healthcare workers (HCWs), based on each center's debriefing reports from 30 countries in all WHO regions. The main outcome measures were the COVID-19 simulations characteristics, facilitators, obstacles, and challenges encountered during the simulation sessions.Results: Invitation was sent to 343 simulation team leaders and multidisciplinary HCWs who responded; 121 completed the survey. The frequency of simulation sessions was monthly (27.1%), weekly (24.8%), twice weekly (19.8%), or daily (21.5%). Regarding the themes of the simulation sessions, they were COVID-19 patient arrival to ER (69.4%), COVID-19 patient intubation due to respiratory failure (66.1%), COVID-19 patient requiring CPR (53.7%), COVID-19 transport inside the hospital (53.7%), COVID-19 elective intubation in OR (37.2%), or Delivery of COVID-19 mother and neonatal care (19%). Among participants, 55.6% reported the team's full engagement in the simulation sessions. The average session length was 30–60 min. The debriefing process was conducted by the ICU facilitator in (51%) of the sessions followed by simulation staff in 41% of the sessions. A total of 80% reported significant improvement in clinical preparedness after simulation sessions, and 70% were satisfied with the COVID-19 sessions. Most perceived issues reported were related to infection control measures, followed by team dynamics, logistics, and patient transport issues.Conclusion: Simulation centers team leaders and HCWs reported positive feedback on COVID-19 simulation sessions with multidisciplinary personnel involvement. These drills are a valuable tool for rehearsing safe dynamics on the frontline of COVID-19. More research on COVID-19 simulation outcomes is warranted; to explore variable factors for each country and healthcare system.