scholarly journals Rationing care by frailty during the COVID-19 pandemic

2020 ◽  
Author(s):  
Emma Grace Lewis ◽  
Matthew Breckons ◽  
Richard P Lee ◽  
Catherine Dotchin ◽  
Richard Walker
Keyword(s):  
Critical Care ◽  
Older People ◽  
Adverse Outcome ◽  
Older Individuals ◽  
Short Term ◽  
Clinical Frailty Scale ◽  
Widespread Implementation ◽  
Care Outcomes ◽  
Resource Allocation Strategy ◽  
The Impact

Abstract The coronavirus disease 2019 (COVID-19) pandemic is disproportionately affecting older people and those with underlying comorbidities. Guidelines are needed to help clinicians make decisions regarding appropriate use of limited NHS critical care resources. In response to the pandemic, the National Institute for Health and Care Excellence published guidance that employs the Clinical Frailty Scale (CFS) in a decision-making flowchart to assist clinicians in assessing older individuals’ suitability for critical care. This commentary raises some important limitations to this use of the CFS and cautions against the potential for unintended impacts. The COVID-19 pandemic has allowed the widespread implementation of the CFS with limited training or expert oversight. The CFS is primarily being used to assess older individuals’ risk of adverse outcome in critical care, and to ration access to care on this basis. While some form of resource allocation strategy is necessary for emergencies, the implementation of this guideline in the absence of significant pressure on resources may reduce the likelihood of older people with frailty, who wish to be considered for critical care, being appropriately considered, and has the potential to reinforce the socio-economic gradient in health. Our incomplete understanding of this novel disease means that there is a need for research investigating the short-term predictive abilities of the CFS on critical care outcomes in COVID-19. Additionally, a review of the impact of stratifying older people by CFS score as a rationing strategy is necessary in order to assess its acceptability to older people as well as its potential for disparate impacts.

Does obesity affect the short-term outcomes after cardiothoracic surgery in adolescents with congenital heart disease?

2020 ◽  
Vol 30 (3) ◽  
pp. 372-376 ◽  
Author(s):  
Richard U. Garcia ◽  
Preetha L. Balakrishnan ◽  
Sanjeev Aggarwal
Keyword(s):  
Body Mass Index ◽  
Congenital Heart Disease ◽  
Heart Disease ◽  
Body Mass ◽  
Congenital Heart ◽  
Adverse Outcome ◽  
Normal Weight ◽  
Adverse Outcomes ◽  
Short Term ◽  
The Impact

AbstractBackground:Obesity is a modifiable, independent risk factor for mortality and morbidity after cardiovascular surgery in adults. Our objective was to evaluate the impact of obesity on short-term outcomes in adolescents undergoing surgery for congenital heart disease (CHD).Methods:This retrospective chart review included patients 10–18 years of age who underwent CHD surgery. Our exclusion criteria were patients with a known genetic syndrome, heart transplantation, and patients with incomplete medical records. The clinical data collected included baseline demographics and multiple perioperative variables. Charting the body mass index in the Centers for Disease Control and Prevention growth curves, the entire cohort was divided into three categories: obese (>95th percentile), overweight (85th–95th percentile), and normal weight (<85th percentile). The composite outcome included survival, arrhythmias, surgical wound infection, acute neurologic injury, and acute kidney injury.Results:The study cohort (n = 149) had a mean standard deviation (SD), body mass index (BMI) of 22.6 ± 6.5 g/m2, and 65% were male. There were 27 obese (18.1%), 24 overweight (16.1%), and 98 normal weight (65.8%) patients. Twenty-seven (18%) patients had composite adverse outcomes. Overweight and obese patients had significantly higher adverse outcomes compared with normal weight patients (odds ratio (OR): 2.9; confidence interval (CI): 1–8.5, p = 0.04 and OR: 3; CI: 1–8.5, p = 0.03, respectively). In multivariate analysis, obesity was an independent predictor of adverse outcome in our cohort (p = 0.04).Conclusions:Obesity is associated with short-term adverse outcome and increased health resource utilisation in adolescents following surgery for CHD. Further studies should evaluate if intervention in the preoperative period can improve outcomes in this population.

The Impact Of Massachusetts Healthcare Insurance Reform On Critical Care Outcomes

2012 ◽  
Author(s):  
Colin R. Cooke ◽  
Sarah M. Lyon ◽  
Hannah Wunsch ◽  
Theodore J. Iwashyna ◽  
Jeremy M. Kahn
Keyword(s):  
Critical Care ◽  
Critical Care Outcomes ◽  
Insurance Reform ◽  
Care Outcomes ◽  
Healthcare Insurance ◽  
The Impact

scholarly journals Insights Into the Effects of Mucosal Epithelial and Innate Immune Dysfunction in Older People on Host Interactions With Streptococcus pneumoniae

2021 ◽  
Vol 11 ◽  
Author(s):  
Caroline M. Weight ◽  
Simon P. Jochems ◽  
Hugh Adler ◽  
Daniela M. Ferreira ◽  
Jeremy S. Brown ◽  
...  
Keyword(s):  
Streptococcus Pneumoniae ◽  
Older People ◽  
Immune Cell ◽  
Herd Immunity ◽  
Pneumococcal Infection ◽  
Innate Immune ◽  
Older Individuals ◽  
Serotype Replacement ◽  
Pneumococcal Colonization ◽  
The Impact

In humans, nasopharyngeal carriage of Streptococcus pneumoniae is common and although primarily asymptomatic, is a pre-requisite for pneumonia and invasive pneumococcal disease (IPD). Together, these kill over 500,000 people over the age of 70 years worldwide every year. Pneumococcal conjugate vaccines have been largely successful in reducing IPD in young children and have had considerable indirect impact in protection of older people in industrialized country settings (herd immunity). However, serotype replacement continues to threaten vulnerable populations, particularly older people in whom direct vaccine efficacy is reduced. The early control of pneumococcal colonization at the mucosal surface is mediated through a complex array of epithelial and innate immune cell interactions. Older people often display a state of chronic inflammation, which is associated with an increased mortality risk and has been termed ‘Inflammageing’. In this review, we discuss the contribution of an altered microbiome, the impact of inflammageing on human epithelial and innate immunity to S. pneumoniae, and how the resulting dysregulation may affect the outcome of pneumococcal infection in older individuals. We describe the impact of the pneumococcal vaccine and highlight potential research approaches which may improve our understanding of respiratory mucosal immunity during pneumococcal colonization in older individuals.

scholarly journals The Impact of Communication Technology and Social Media on Intergenerational Relationships between Older Individuals and Their Adult Children in Bangkok

MANUSYA ◽  
2020 ◽  
Vol 23 (2) ◽  
pp. 188-204
Author(s):  
Marie-Helene Thomas
Keyword(s):  
Social Media ◽  
Older People ◽  
Communication Technology ◽  
Adult Children ◽  
Instant Messaging ◽  
Smart Phone ◽  
Intergenerational Relationships ◽  
Older Individuals ◽  
Intergenerational Relationship ◽  
The Impact

Modernisation theory (Cowgill and Holmes 1972) argues that older people in modern societies are less respected and valued as a result of technological innovations. To understand the impact of communication technology and social media on Thai society, this research studies the transformations in communication, interaction and overall connectedness between older people and their adult children. In addition, it examines what elements have shifted due to the introduction and use of the smart phone and its accompanying instant messaging and social media applications such as Line and Facebook. The data demonstrates various positive and negative impacts on the intergenerational relationship between older parents and their child cohorts. Crucially, countless examples and arguments from the respondents suggest that the use of these new tools of communication has a very real and demonstrable impact, from providing a space for family members to express their emotions to being the culprit that divides the family unit.

scholarly journals 12-Hour nursing shifts in critical care: A service evaluation

2018 ◽  
Vol 19 (3) ◽  
pp. 214-218 ◽  
Author(s):  
Ceri Battle ◽  
Paul Temblett
Keyword(s):  
Critical Care ◽  
Healthcare Provider ◽  
Service Evaluation ◽  
Critical Care Nursing ◽  
Single Centre ◽  
Burn Out ◽  
Single Centre Study ◽  
Care Outcomes ◽  
Provider Outcomes ◽  
The Impact

The aim of this single-centre study was to investigate the impact of the introduction of 12-h critical care nursing shifts on healthcare provider and patient care outcomes. A single-centre, prospective service evaluation was completed over a two-year period, comparing the 8-h and 12-h shifts. Outcomes included number of clinical incidents, levels of burn-out, sick rates, personal injuries and training. There were no significant differences between the clinical incidents, sickness rates, personal injuries and staff training between the two data collection periods. The results of the burn-out analysis demonstrate that emotional exhaustion and depersonalisation improved, from the 8-h to 12-h shifts (both p < 0.05). In conclusion, the results of this service evaluation have demonstrated that 12-h nursing shifts can be introduced safely into the critical care environment, without any detriment to patient or healthcare provider outcomes.

scholarly journals 334 GEMS: Geriatric Emergency Service - Rockwood’s Clinical Frailty Scale and Outcomes

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Danielle Reddy ◽  
Grainne Gallagher ◽  
Maureen O'Callaghan ◽  
Lorna Cornally ◽  
Megan Hayes Brennan ◽  
...  
Keyword(s):  
Older Adults ◽  
Length Of Stay ◽  
Older People ◽  
Patient Experience ◽  
Emergency Service ◽  
Strong Predictor ◽  
Canadian Study ◽  
Clinical Frailty Scale ◽  
Care Outcomes

Abstract Background Rockwood’s Clinical Frailty Scale (CFS), which uses clinical descriptors and pictographs, was developed to provide clinicians with an easily applicable tool to stratify older adults according to level of vulnerability. The CFS was validated in a sample of 2305 older participants from the Canadian Study of Health and Aging and was shown to be a strong predictor of institutionalisation and mortality (Rockwood K, 2005). Methods The aim of GEMS is to improve care, outcomes and the patient experience for older people living with Frailty. All people aged 75 years and older who attend as an emergency are screened on triage using the Variable Indicative of Placement Tool (VIP). The GEMS Acute Floor Team respond early to those who screen positive by starting a CGA. At the end of CGA all patients have a score 1 to 9 assigned from the Clinical Frailty Scale (CFS). Results 10,037 patients were triaged in the first two years of the service. 43% screened positive for Frailty. 66% had a CGA. 10% were vulnerable CFS 4, 32% mildly frail CFS 5, 32% moderately frail CFS 6 and 31% severely frail CFS 7. Increasing score on the CFS correlated with increased length of stay, death and institutionalisation. Conclusion The CFS correlates with Length of stay (LOS), mortality and institutionalisation in people aged 75 years and older who attend as an emegency and screen positive for Frailty.

scholarly journals Ageing alters the impact of nutrition on immune function

2016 ◽  
Vol 76 (3) ◽  
pp. 347-351 ◽  
Author(s):  
Parveen Yaqoob
Keyword(s):  
Older People ◽  
Immune Function ◽  
Metabolic Regulation ◽  
Immune Cell ◽  
Older Individuals ◽  
Age Related ◽  
Dietary Strategies ◽  
Future Work ◽  
The Impact ◽  
Result Interpretation

Immunosenescence during ageing is a major challenge which weakens the ability of older individuals to respond to infection or vaccination. There has been much interest in dietary strategies to improve immunity in older people, but there is an assumption that modulation of the immune response in older people will be based on the same principles as for younger adults. Recent evidence suggests that ageing fundamentally alters the impact of nutrition on immune function. As a result, interpretation of data from studies investigating the impact of diet on immune function is highly dependent on subject age. Study design is critically important when investigating the efficacy of dietary components, and most studies involving older people include rigorous inclusion/exclusion criteria based on medical history, laboratory tests, general health status and often nutritional status. However, immunological status is rarely accounted for, but can vary significantly, even amongst healthy older people. There are several clear examples of age-related changes in immune cell composition, phenotype and/or function, which can directly alter the outcome of an intervention. This review uses two case studies to illustrate how the effects of n-3 PUFA and probiotics differ markedly in young v. older subjects. Evidence from both suggests that baseline differences in immunosenescence influence the outcome of an intervention, highlighting the need for detailed immunological characterisation of subjects prior to interventions. Finally, future work elucidating alterations in metabolic regulation within cells of the immune system as a result of ageing may be important in understanding the impact of diet on immune function in older people.

scholarly journals The impact of SARS-CoV-2 vaccines on antibody responses in the general population in the United Kingdom

2021 ◽  
Author(s):  
Jia Wei ◽  
Nicole Stoesser ◽  
Philippa C. Matthews ◽  
Ruth Studley ◽  
Iain Bell ◽  
...  
Keyword(s):  
Single Dose ◽  
General Population ◽  
Older People ◽  
Latent Class ◽  
Latent Class Models ◽  
Antibody Responses ◽  
Older Individuals ◽  
Antibody Levels ◽  
The Impact ◽  
Prior Infection

AbstractReal-world data on antibody response post-vaccination in the general population are limited. 45,965 adults in the UK’s national COVID-19 Infection Survey receiving Pfizer-BioNTech or Oxford-AstraZeneca vaccines had 111,360 anti-spike IgG measurements. Without prior infection, seroconversion rates and quantitative antibody levels post single dose were lower in older individuals, especially >60y. Two doses achieved high responses across all ages, particularly increasing seroconversion in older people, to similar levels to those achieved after prior infection followed by a single dose. Antibody levels rose more slowly and to lower levels with Oxford-AstraZeneca vs Pfizer-BioNTech, but waned following a single Pfizer-BioNTech dose. Latent class models identified four responder phenotypes: older people, males, and those having long-term health conditions were more commonly ‘low responders’. Where supplies are limited, vaccines should be prioritised for those not previously infected, and second doses to individuals >60y. Further data on the relationship between vaccine-mediated protection and antibody responses are needed.

scholarly journals An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study

2020 ◽  
pp. 088506662093102
Author(s):  
Amelia Barwise ◽  
Chung-Il Wi ◽  
Ryan Frank ◽  
Bojana Milekic ◽  
Nicole Andrijasevic ◽  
...  
Keyword(s):  
Older Adults ◽  
Socioeconomic Status ◽  
Critical Care ◽  
Intensive Care ◽  
Population Based ◽  
Adult Patients ◽  
Critical Care Outcomes ◽  
Individual Level ◽  
Care Outcomes ◽  
The Impact

Background: Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults. Objective: We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission. Methods: We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old). Results: Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051). Conclusion: Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.

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