239. Outcomes Associated with Empiric Aztreonam Use Compared to Anti-Pseudomonal β-lactams in Patients with Sepsis: An Opportunity for Allergy Stewardship

Abstract Background Aztreonam is often given to patients with a documented β-lactam allergy in lieu of a first-line anti-pseudomonal β-lactam (APBL). However, aztreonam offers no gram positive coverage and data suggest that gram negative organisms have lower susceptibility rates to this antibiotic than to APBLs. Septic patients are especially vulnerable to poor outcomes since inappropriate initial antimicrobial therapy has been shown to be an independent predictor of increased mortality. The purpose of this study was to determine whether septic patients treated with aztreonam experience inferior outcomes compared to those treated with an APBL. Methods This was a retrospective, multicenter, cohort study of all adult patients in metro Charlotte Atrium Health facilities treated for sepsis or septic shock from January 2014 to October 2017. Patients receiving either aztreonam or an APBL were identified using the system-wide sepsis database and enrolled in a 1:2 ratio. Patients were excluded if there was no infection-related discharge ICD-9 or ICD-10 code, if they received both aztreonam and an APBL in the first 8 hours, or if they received fewer than 2 doses of the study antibiotic. The primary endpoint was in-hospital mortality. Results A total of 194 patients received aztreonam and 388 patients received an APBL. β-lactam allergies were more common in patients who received aztreonam compared to APBL (97% vs. 14.2%, p < 0.01). In-hospital mortality rates were greater in the patients who received aztreonam vs. APBL (22.7% vs. 12.9%, p = 0.0025). After adjusting for APACHE II score, initial aztreonam exposure remained independently associated with hospital mortality (OR = 1.74, 95% CI: 1.0 – 2.8, p = 0.02). Additionally, we identified an increase in combination therapy with the use of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.0001) in patients receiving aztreonam. No difference was found in overall length of stay or ICU length of stay. Conclusion In septic patients, the use of aztreonam as the backbone of antimicrobial therapy may result in increased mortality. This highlights the importance of stewardship interventions that obtain an accurate allergy history and encourage the use of APBL antibiotics whenever feasible. Disclosures Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)

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Hospital Volume is Not a Predictor of Outcomes after Gastrectomy for Neoplasm

The American Surgeon ◽

10.1177/000313480907501015 ◽

2009 ◽

Vol 75 (10) ◽

pp. 932-936 ◽

Cited By ~ 5

Author(s):

Kevin M. Reavis ◽

Marcelo W. Hinojosa ◽

Brian R. Smith ◽

James B. Wooldridge ◽

Sindhu Krishnan ◽

...

Keyword(s):

Length Of Stay ◽

Hospital Mortality ◽

Gastric Surgery ◽

National Database ◽

Medical Centers ◽

Outcome Relationship ◽

Academic Medical ◽

Low Volume ◽

Poor Outcomes ◽

The University

Studies have shown conflicting data with regard to the volume and outcome relationship for gastrectomy. Using the University HealthSystem Consortium national database, we examined the influence of the hospital's volume of gastrectomy on outcomes at academic centers between 2004 and 2008. Outcome measures, including length of stay, 30-day readmission, morbidity, and in-hospital mortality, were compared among high- (13 or greater), medium- (6 to 12), and low-volume (five or less) hospitals. There were 10 high- (n = 593 cases), 36 medium- (n = 1076 cases), and 75 low-volume (n = 500 cases) hospitals. There were no significant differences between high- and low-volume hospitals with regard to length of stay, overall complications, 30-day readmission rate, and in-hospital mortality (2.4 vs 4.4%, respectively, P = 0.06). Despite the small number of gastrectomies performed at the low-volume hospitals, these same hospitals performed a large number of other types of gastric surgery such as gastric bypass for the treatment of morbid obesity (102 cases/year). Within the context of academic medical centers, lower annual volume of gastrectomy for neoplasm is not a predictor of poor outcomes which may be explained by the gastric operative experience derived from other types of gastric surgery.

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In-Hospital Mortality and Related Outcomes for Elevated Risk Acute Pulmonary Embolism Treated With Mechanical Thrombectomy Versus Routine Care

Journal of Intensive Care Medicine ◽

10.1177/08850666211036446 ◽

2021 ◽

pp. 088506662110364

Author(s):

Jennifer R. Buckley ◽

Brandt C. Wible

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Length Of Stay ◽

Hospital Mortality ◽

Routine Care ◽

Hospital Length ◽

Elevated Risk ◽

Hospital Length Of Stay ◽

Icu Length Of Stay

Purpose To compare in-hospital mortality and other hospitalization related outcomes of elevated risk patients (Pulmonary Embolism Severity Index [PESI] score of 4 or 5, and, European Society of Cardiology [ESC] classification of intermediate-high or high risk) with acute central pulmonary embolism (PE) treated with mechanical thrombectomy (MT) using the Inari FlowTriever device versus those treated with routine care (RC). Materials and Methods Retrospective data was collected of all patients with acute, central PE treated at a single institution over 2 concurrent 18-month periods. All collected patients were risk stratified using the PESI and ESC Guidelines. The comparison was made between patients with acute PE with PESI scores of 4 or 5, and, ESC classification of intermediate-high or high risk based on treatment type: MT and RC. The primary endpoint evaluated was in-hospital mortality. Secondary endpoints included intensive care unit (ICU) length of stay, total hospital length of stay, and 30-day readmission. Results Fifty-eight patients met inclusion criteria, 28 in the MT group and 30 in the RC group. Most RC patients were treated with systemic anticoagulation alone (24 of 30). In-hospital mortality was significantly lower for the MT group than for the RC group (3.6% vs 23.3%, P < .05), as was the average ICU length of stay (2.1 ± 1.2 vs 6.1 ± 8.6 days, P < .05). Total hospital length of stay and 30-day readmission rates were similar between MT and RC groups. Conclusion Initial retrospective comparison suggests MT can improve in-hospital mortality and decrease ICU length of stay for patients with acute, central PE of elevated risk (PESI 4 or 5, and, ESC intermediate-high or high risk).

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Relationship between availability of physiotherapy services and ICU costs

Jornal Brasileiro de Pneumologia ◽

10.1590/s1806-37562017000000196 ◽

2018 ◽

Vol 44 (3) ◽

pp. 184-189 ◽

Cited By ~ 4

Author(s):

Bruna Peruzzo Rotta ◽

Janete Maria da Silva ◽

Carolina Fu ◽

Juliana Barbosa Goulardins ◽

Ruy de Camargo Pires-Neto ◽

...

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Invasive Mechanical Ventilation ◽

Severity Of Illness ◽

Apache Ii Score ◽

Health Evaluation ◽

Icu Length Of Stay ◽

Tertiary Teaching ◽

Tertiary Teaching Hospital ◽

First Time

ABSTRACT Objective: To determine whether 24-h availability of physiotherapy services decreases ICU costs in comparison with the standard 12 h/day availability among patients admitted to the ICU for the first time. Methods: This was an observational prevalence study involving 815 patients ≥ 18 years of age who had been on invasive mechanical ventilation (IMV) for ≥ 24 h and were discharged from an ICU to a ward at a tertiary teaching hospital in Brazil. The patients were divided into two groups according to h/day availability of physiotherapy services in the ICU: 24 h (PT-24; n = 332); and 12 h (PT-12; n = 483). The data collected included the reasons for hospital and ICU admissions; Acute Physiology and Chronic Health Evaluation II (APACHE II) score; IMV duration, ICU length of stay (ICU-LOS); and Omega score. Results: The severity of illness was similar in both groups. Round-the-clock availability of physiotherapy services was associated with shorter IMV durations and ICU-LOS, as well as with lower total, medical, and staff costs, in comparison with the standard 12 h/day availability. Conclusions: In the population studied, total costs and staff costs were lower in the PT-24 group than in the PT-12 group. The h/day availability of physiotherapy services was found to be a significant predictor of ICU costs.

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Abstract 16110: Impact of Institutional Volume on In-hospital Mortality and Resource Utilization Among Patients With Pulmonary Embolism Treated With Catheter Directed Thrombolysis: A Population-Based Cohort Study

Circulation ◽

10.1161/circ.142.suppl_3.16110 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Isaac C Meier ◽

Beau M Hawkins ◽

Federico Silva ◽

TALLA ROUSAN ◽

Mohan Edupuganti ◽

...

Keyword(s):

Pulmonary Embolism ◽

Length Of Stay ◽

Hospital Mortality ◽

Population Based ◽

Data Sets ◽

Percutaneous Approach ◽

Catheter Directed Thrombolysis ◽

Procedural Volume ◽

Icd 10 ◽

Institutional Volume

Introduction: Catheter-directed thrombolysis (CDT) is an evolving percutaneous approach for the management of acute pulmonary embolism (PE). Contemporary data examining in-hospital outcomes in relation to procedural volume are limited. Methods: Data sets were extracted from the 2016 national readmission database. Using ICD 10 codes, a search was performed to identify all patients hospitalized with a primary or secondary diagnosis of PE who underwent CDT between 1/1/2016 and 12/31/2016. Hospitals were grouped into quartiles by CDT volume and rates of in-hospital mortality, length of stay, and cost were compared across groups. Adjusted associations were examined using multivariable logistic regression. Results and Conclusions: We identified 2,353 unique patients with PE who underwent CDT at 483 hospitals. The median (25th, 75th percentiles) number of CDT procedures per hospital was 3 (1, 6). Mortality rates were 11.4%, 5.3%, 5.6% and 3.8%, respectively, at hospitals in the 1st, 2nd, 3rd and 4th quartile of CDT procedural volume (Figure; p=0.001). Results were unchanged after multivariable adjustment. Median length of stay by quartile was as follows: 6.5, 5, 5, and 4 days (p <0.001). The median cost for the different quartiles was $28,277, $25,953, $25,896, and $23,007 (p <0.001). We found that CDT performed in patients with PE at low-volume hospitals is associated with excess mortality as well as increased length of stay and cost when compared with higher-volume centers. These findings may inform guidance for volume thresholds for utilization of CDT in the management of acute PE.

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Whole body perfusion strategy for aortic arch repair under moderate hypothermia

Perfusion ◽

10.1177/0267659117724864 ◽

2017 ◽

Vol 33 (4) ◽

pp. 254-263 ◽

Cited By ~ 4

Author(s):

Christopher L. Tarola ◽

Katie L. Losenno ◽

Jill J. Gelinas ◽

Philip M. Jones ◽

Philip Fernandes ◽

...

Keyword(s):

Length Of Stay ◽

Hospital Mortality ◽

Aortic Arch ◽

Whole Body ◽

Moderate Hypothermia ◽

Lower Body ◽

Icu Length Of Stay ◽

Icu Discharge ◽

Aortic Arch Reconstruction ◽

Arch Reconstruction

Introduction: Aortic arch reconstruction under moderate hypothermia is commonly performed with antegrade cerebral perfusion (ACP) for brain protection; however, hypothermia alone is often solely relied upon for visceral and lower body protection. We investigated whether the addition of simultaneous lower body perfusion to ACP (whole body perfusion - WBP) may ameliorate the metabolic derangements of moderate hypothermic circulatory arrest (MHCA). Methods: Between 2008 and 2014, 106 consecutive patients underwent elective or emergent aortic arch surgery with MHCA, with either ACP only (44 patients, 66±12 years, 30% female) or WBP (62 patients, 61±15 years, 31% female). Primary outcomes included 30-day/in-hospital mortality, intensive care unit (ICU) and hospital lengths of stay (LOS) and specific parameters of metabolic recovery. Results: There were no significant differences between the groups in 30-day/in-hospital mortality (ACP: 3 (6.8%), WBP: 2 (3.2%); p=0.65), stroke (ACP: 1 (2.3%), WBP: 1 (1.6%); p=1.0) or renal failure (ACP: 2 (4.5%), WBP: 1 (1.5%); p=0.57). In the WBP group, we identified a significant reduction in lactate level at ICU admission (ACP 5.5 vs. WBP 3.5 mmol/L; p=0.002), time to lactate normalization (p=0.014) and median ICU length-of-stay (ACP 3 vs. WBP 1 days; p=0.049). There was no difference in post-operative creatinine (ACP: 104, WBP: 107 μmol/L; p=0.66). After multivariable regression adjustment, perfusion strategy no longer remained an independent predictor of ICU discharge time (p=0.09), however, cardiopulmonary bypass time (p=0.02), age (p=0.012) and emergent surgery (p=0.02) were. Conclusions: A WBP strategy during aortic arch reconstruction with MHCA may be associated with more rapid normalization of metabolic parameters and reduced ICU length of stay compared to using ACP alone. Further evaluation with a randomized trial is warranted.

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Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison

World Journal of Surgery ◽

10.1007/s00268-018-4669-8 ◽

2018 ◽

Vol 42 (11) ◽

pp. 3608-3615 ◽

Cited By ~ 6

Author(s):

Suzan Dijkink ◽

Pieta Krijnen ◽

Aglaia Hage ◽

Gwendolyn M. Van der Wilden ◽

George Kasotakis ◽

...

Keyword(s):

Length Of Stay ◽

The Netherlands ◽

Hospital Mortality ◽

Penetrating Trauma ◽

Admission Rate ◽

Population Characteristics ◽

Penetrating Injuries ◽

Icu Length Of Stay ◽

Revised Trauma Score ◽

The Usa

AbstractIntroductionThe incidence and nature of penetrating injuries differ between countries. The aim of this study was to analyze characteristics and clinical outcomes of patients with penetrating injuries treated at urban Level-1 trauma centers in the USA (USTC) and the Netherlands (NLTC).MethodsIn this retrospective cohort study, 1331 adult patients (470 from five NLTC and 861 from three USTC) with truncal penetrating injuries admitted between July 2011 and December 2014 were included. In-hospital mortality was the primary outcome. Outcome comparisons were adjusted for differences in population characteristics in multivariable analyses.ResultsIn USTC, gunshot wound injuries (36.1 vs. 17.4%,p < 0.001) and assaults were more frequent (91.2 vs. 77.7%,p < 0.001). ISS was higher in USTC, but the Revised Trauma Score (RTS) was comparable. In-hospital mortality was similar (5.0 vs. 3.6% in NLTC,p = 0.25). The adjusted odds ratio for mortality in USTC compared to NLTC was 0.95 (95% confidence interval 0.35–2.54). Hospital stay length of stay was shorter in USTC (difference 0.17 days, 95% CI −0.29 to −0.05,p = 0.005), ICU admission rate was comparable (OR 0.96, 95% CI 0.71–1.31,p = 0.80), and ICU length of stay was longer in USTC (difference of 0.39 days, 95% CI 0.18–0.60,p < 0.0001). More USTC patients were discharged to home (86.9 vs. 80.6%,p < 0.001). Readmission rates were similar (5.6 vs. 3.8%,p = 0.17).ConclusionDespite the higher incidence of penetrating trauma, particularly firearm-related injuries, and higher hospital volumes in the USTC compared to the NLTC, the in-hospital mortality was similar. In this study, outcome of care was not significantly influenced by differences in incidence of firearm-related injuries.

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Impact of Vasopressor Initiation and Discontinuation Sequence on Mortality in Septic Shock: A Retrospective Review

Surgical Case Reports ◽

10.31487/j.scr.2020.01.05 ◽

2020 ◽

pp. 1-7

Author(s):

Cara McDaniel ◽

Andrew Moyer ◽

Cara McDaniel ◽

Judah Brown ◽

Michael Baram

Keyword(s):

Septic Shock ◽

Length Of Stay ◽

Hospital Mortality ◽

Primary Endpoint ◽

Primary Diagnosis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Apache Ii Score ◽

Vasoactive Agent ◽

Intra Abdominal Infection

Background: Little data exists guiding clinicians on how or when to initiate and discontinue the second vasoactive agent in the setting of septic shock refractory to norepinephrine monotherapy. Methods: This retrospective cohort study evaluated patients with a primary diagnosis of septic shock admitted to the intensive care unit receiving norepinephrine in addition to concomitant vasopressors. The primary endpoint was the incidence of all-cause in-hospital mortality when adding adjunctive vasopressors to norepinephrine either before the dose reached 2 mcg/kg/min (early adjunctive vasopressor) or after (late adjunctive vasopressor). Secondary endpoints included the incidence of clinically significant hypotension when discontinuing norepinephrine before or after vasopressin in the same population. Results: Forty-six patients were included (early adjunctive vasopressor [n=36]; late adjunctive vasopressor [n=10]), with a median age of 69 years and APACHE II score of 27. Fewer patients in the early adjunctive vasopressor cohort had malignancy prior to admission (16.7% vs. 60%, p=0.0117), however, more patients were managed in the surgical ICU (44.4% vs. 0%, p=0.0202) with intra-abdominal infection (33.3% vs. 0%, p=0.0439). The primary endpoint of all-cause in-hospital mortality was not statistically different between the early and late adjunctive vasopressor groups (75% vs. 90%, respectively, p=0.4203). Longer ICU and hospital length of stay in the early adjunctive vasopressor cohort was observed (9 days vs 3 days, p=0.0061; 11 days vs 3 days, p=0.0026, respectively). Twenty-two patients were included in analysis of vasopressor discontinuation sequence with no significant differences in mortality, incidence of hypotension, or ICU/hospital length of stay. Conclusion: Among patients with septic shock on multiple vasopressors, addition of adjunctive vasopressor before reaching a norepinephrine dose of 2 mcg/kg/min was associated with longer in-hospital and ICU survival but exhibited no difference in overall mortality. Discontinuation of vasopressin before norepinephrine led to longer total vasopressor duration without a difference in rates of hypotension. Future prospective studies are warranted.

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Characteristics and resource utilization of high-cost users in the intensive care unit: a population-based cohort study

BMC Health Services Research ◽

10.1186/s12913-021-07318-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Claudia Dziegielewski ◽

Robert Talarico ◽

Haris Imsirovic ◽

Danial Qureshi ◽

Yasmeen Choudhri ◽

...

Keyword(s):

Intensive Care Unit ◽

Cohort Study ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Healthcare Costs ◽

Healthcare Expenditure ◽

Healthcare Spending ◽

Population Based ◽

Icu Length Of Stay

Abstract Background Healthcare expenditure within the intensive care unit (ICU) is costly. A cost reduction strategy may be to target patients accounting for a disproportionate amount of healthcare spending, or high-cost users. This study aims to describe high-cost users in the ICU, including health outcomes and cost patterns. Methods We conducted a population-based retrospective cohort study of patients with ICU admissions in Ontario from 2011 to 2018. Patients with total healthcare costs in the year following ICU admission (including the admission itself) in the upper 10th percentile were defined as high-cost users. We compared characteristics and outcomes including length of stay, mortality, disposition, and costs between groups. Results Among 370,061 patients included, 37,006 were high-cost users. High-cost users were 64.2 years old, 58.3% male, and had more comorbidities (41.2% had ≥3) when likened to non-high cost users (66.1 years old, 57.2% male, 27.9% had ≥3 comorbidities). ICU length of stay was four times greater for high-cost users compared to non-high cost users (22.4 days, 95% confidence interval [CI] 22.0–22.7 days vs. 5.56 days, 95% CI 5.54–5.57 days). High-cost users had lower in-hospital mortality (10.0% vs.14.2%), but increased dispositioning outside of home (77.4% vs. 42.2%) compared to non-high-cost users. Total healthcare costs were five-fold higher for high-cost users ($238,231, 95% CI $237,020–$239,442) compared to non-high-cost users ($45,155, 95% CI $45,046–$45,264). High-cost users accounted for 37.0% of total healthcare costs. Conclusion High-cost users have increased length of stay, lower in-hospital mortality, and higher total healthcare costs when compared to non-high-cost users. Further studies into cost patterns and predictors of high-cost users are necessary to identify methods of decreasing healthcare expenditure.

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Influence of time elapsed from end of emergency surgery until admission to intensive care unit, on Acute Physiology and Chronic Health Evaluation II (APACHE II) prediction and patient mortality rate

Sao Paulo Medical Journal ◽

10.1590/s1516-31802005000400003 ◽

2005 ◽

Vol 123 (4) ◽

pp. 167-174 ◽

Cited By ~ 12

Author(s):

Paulo Antonio Chiavone ◽

Samir Rasslan

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Mortality Rate ◽

Length Of Stay ◽

Hospital Mortality ◽

Emergency Surgery ◽

Apache Ii ◽

Apache Ii Score ◽

Death Risk ◽

Expected Mortality

CONTEXT AND OBJECTIVE: Patients are often admitted to intensive care units with delay in relation to when this service was indicated. The objective was to verify whether this delay influences hospital mortality, length of stay in the unit and hospital, and APACHE II prediction. DESIGN AND SETTING: Prospective and accuracy study, in intensive care unit of Santa Casa de São Paulo, a tertiary university hospital. METHODS: We evaluated all 94 patients admitted following emergency surgery, from August 2002 to July 2003. The variables studied were APACHE II, death risk, length of stay in the unit and hospital, and hospital mortality rate. The patients were divided into two groups according to the time elapsed between end of surgery and admission to the unit: up to 12 hours and over 12 hours. RESULTS: The groups were similar regarding gender, age, diagnosis, APACHE II score and hospital stay. The death risk factors were age, APACHE II and elapsed time (p < 0.02). The mortality rate for the over 12-hour group was higher (54% versus 26.1%; p = 0.018). For the over 12-hour group, observed mortality was higher than expected mortality (p = 0.015). For the up to 12-hour group, observed and expected mortality were similar (p = 0.288). CONCLUSION: APACHE II foresaw the mortality rate among patients that arrived faster to the intensive care unit, while the mortality rate was higher among those patients whose admission to the intensive care unit took longer.

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