scholarly journals Code status documentation at admission in COVID-19 patients: a descriptive cohort study

BMJ Open ◽  
2021 ◽  
Vol 11 (11) ◽  
pp. e050268
Author(s):  
Saskia Briedé ◽  
Harriet M R van Goor ◽  
Titus A P de Hond ◽  
Sonja E van Roeden ◽  
Judith M Staats ◽  
...  
Keyword(s):  
Cohort Study ◽  
Intensive Care ◽  
Tertiary Care ◽  
Secondary Outcome ◽  
Academic Hospital ◽  
Medical Field ◽  
Intensive Care Admission ◽  
Code Status ◽  
Public Media ◽  
Treatment Limitation

ObjectivesThe COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients.SettingUniversity Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands.ParticipantsA total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018).Primary and secondary outcome measuresWe described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status.ResultsFrequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, ‘no intensive care admission’ (81% vs 51%) and ‘no intubation’ (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in ‘other limitation’ (17% vs 9%), while ‘no resuscitation’ (96% vs 92%) was comparable between both periods.ConclusionWe observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially ‘no intubation’ and ‘no intensive care admission’.

scholarly journals Early resuscitation orders in hospitalized oldest-old with COVID-19: A multicenter cohort study

2021 ◽  
pp. 026921632110183
Author(s):  
Ruth Piers ◽  
Eva Van Braeckel ◽  
Dominique Benoit ◽  
Nele Van Den Noortgate
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Respiratory Failure ◽  
Hospital Mortality ◽  
Oldest Old ◽  
Case Report Form ◽  
Resuscitation Orders ◽  
Intensive Care Admission ◽  
Treatment Limitation ◽  
Early Decision

Background: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is essential to assist patient autonomy and prevent non-beneficial medical interventions. Aim: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19. Setting/participants: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians. Results: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in 474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty ( p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1% in persons who developed respiratory failure vs 16.7% in patients without respiratory failure ( p < 0.001)). Of 104 patients without early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%. Conclusions: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of conservative treatment.

scholarly journals Delirium and neuropsychological outcomes in critically Ill patients with COVID-19: a cohort study

BMJ Open ◽  
2021 ◽  
Vol 11 (9) ◽  
pp. e050045
Author(s):  
Jacqueline Ragheb ◽  
Amy McKinney ◽  
Mackenzie Zierau ◽  
Joseph Brooks ◽  
Maria Hill-Caruthers ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Cognitive Impairment ◽  
Chart Review ◽  
Tertiary Care ◽  
Secondary Outcome ◽  
Contributing Factors ◽  
Ischaemic Injury ◽  
Patient Reported ◽  
Neuropsychological Outcomes

ObjectiveTo characterise the clinical course of delirium for patients with COVID-19 in the intensive care unit, including postdischarge neuropsychological outcomes.DesignRetrospective chart review and prospective survey study.SettingIntensive care units, large academic tertiary-care centre (USA).ParticipantsPatients (n=148) with COVID-19 admitted to an intensive care unit at Michigan Medicine between 1 March 2020 and 31 May 2020 were eligible for inclusion.Primary and secondary outcome measuresDelirium was the primary outcome, assessed via validated chart review method. Secondary outcomes included measures related to delirium, such as delirium duration, antipsychotic use, length of hospital and intensive care unit stay, inflammatory markers and final disposition. Neuroimaging data were also collected. Finally, a telephone survey was conducted between 1 and 2 months after discharge to determine neuropsychological function via the following tests: Family Confusion Assessment Method, Short Blessed Test, Patient-Reported Outcomes Measurement Information System Cognitive Abilities 4a and Patient-Health Questionnaire-9.ResultsDelirium was identified in 108/148 (73%) patients, with median (IQR) duration lasting 10 (4–17) days. In the delirium cohort, 50% (54/108) of patients were African American and delirious patients were more likely to be female (76/108, 70%) (absolute standardised differences >0.30). Sedation regimens, inflammation, delirium prevention protocol deviations and hypoxic-ischaemic injury were likely contributing factors, and the most common disposition for delirious patients was a skilled care facility (41/108, 38%). Among patients who were delirious during hospitalisation, 4/17 (24%) later screened positive for delirium at home based on caretaker assessment, 5/22 (23%) demonstrated signs of questionable cognitive impairment or cognitive impairment consistent with dementia and 3/25 (12%) screened positive for depression within 2 months after discharge.ConclusionPatients with COVID-19 commonly experience a prolonged course of delirium in the intensive care unit, likely with multiple contributing factors. Furthermore, neuropsychological impairment may persist after discharge.

scholarly journals Evaluating antimicrobial appropriateness in a tertiary care pediatric ICU in Saudi Arabia: a retrospective cohort study

2020 ◽  
Vol 9 (1) ◽  
Author(s):  
Yasser M. Kazzaz ◽  
Haneen AlTurki ◽  
Lama Aleisa ◽  
Bashaer Alahmadi ◽  
Nora Alfattoh ◽  
...  
Keyword(s):  
Saudi Arabia ◽  
Cohort Study ◽  
Intensive Care ◽  
Antimicrobial Resistance ◽  
Retrospective Cohort ◽  
Tertiary Care ◽  
Antibiotic Use ◽  
Antibiotic Consumption ◽  
Antibiotic Utilization ◽  
Antibiotic Courses

Abstract Background Inappropriate antibiotic utilization is associated with the emergence of antimicrobial resistance (AMR) and a decline in antibiotic susceptibility in many pathogenic organisms isolated in intensive care units. Antibiotic stewardship programs (ASPs) have been recommended as a strategy to reduce and delay the impact of AMR. A crucial step in ASPs is understanding antibiotic utilization practices and quantifying the problem of inappropriate antibiotic use to support a targeted solution. We aim to characterize antibiotic utilization and determine the appropriateness of antibiotic prescription in a tertiary care pediatric intensive care unit. Methods A retrospective cohort study was conducted at King Abdullah Specialized Children’s Hospital, Riyadh, Saudi Arabia, over a 6-month period. Days of therapy (DOT) and DOT per 1000 patient-days were used as measures of antibiotic consumption. The appropriateness of antibiotic use was assessed by two independent pediatric infectious disease physicians based on the Centers for Disease Control and Prevention 12-step Campaign to prevent antimicrobial resistance among hospitalized children. Results During the study period, 497 patients were admitted to the PICU, accounting for 3009 patient-days. A total of 274 antibiotic courses were administered over 2553 antibiotic days. Forty-eight percent of antibiotic courses were found to be nonadherent to at least 1 CDC step. The top reasons were inappropriate antibiotic choice (empirical or definitive) and inappropriate prophylaxis durations. Cefazolin and vancomycin contributed to the highest percentage of inappropriate DOTs. Conclusions Antibiotic consumption was high with significant inappropriate utilization. These data could inform decision-making in antimicrobial stewardship programs and strategies. The CDC steps provide a more objective tool and limit biases when assessing antibiotic appropriateness

scholarly journals Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e035733
Author(s):  
Gloria-Beatrice Wintermann ◽  
Kerstin Weidner ◽  
Bernhard Strauss ◽  
Jenny Rosendahl
Keyword(s):  
Quality Of Life ◽  
Cohort Study ◽  
Intensive Care ◽  
Critical Illness ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Care Hospital ◽  
Chronically Critically Ill ◽  
Post Hoc

ObjectivesTo assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients.DesignA prospective cohort study.SettingA tertiary care hospital with postacute intensive care units (ICUs) in Germany.ParticipantsN=267 CCI patients with critical illness polyneuropathy and/or critical illness myopathy, aged 18–75 years, who had undergone elective tracheotomy for weaning failure.InterventionsNone.MeasuresPrimary outcomes: DS was assessed using the Confusion Assessment Method for the Intensive Care Unit-7 delirium severity score, within 4 weeks (t1) after the transfer to a tertiary care hospital. In post hoc analyses, univariate linear regressions were employed, examining the relationship of DS with clinical, sociodemographic and psychological variables. Secondary outcomes: additionally, correlations of DS with fatigue (using the Multidimensional Fatigue Inventory-20), quality of life (using the Euro-Quality of Life) and institutionalisation/mortality at 3 (t2) and 6 (t3) months follow-up were computed.ResultsOf the N=267 patients analysed, 9.4% showed severe or most severe delirium symptoms. 4.1% had a full-syndromal delirium. DS was significantly associated with the severity of illness (p=0.016, 95% CI −0.1 to −0.3), number of medical comorbidities (p<0.001, 95% CI .1 to .3) and sepsis (p<0.001, 95% CI .3 to 1.0). Patients with a higher DS at postacute ICU (t1), showed a higher mental fatigue at t2 (p=0.008, 95% CI .13 to .37) and an increased risk for institutionalisation/mortality (p=0.043, 95% CI 1.1 to 28.9/p=0.015, 95% CI 1.5 to 43.2).ConclusionsIllness severity is positively associated with DS during postacute care in CCI patients. An adequate management of delirium is essential in order to mitigate functional and cognitive long-term sequelae following ICU.Trial registration numberDRKS00003386.

scholarly journals Prediction of early unplanned intensive care unit readmission in a UK tertiary care hospital: a cross-sectional machine learning approach

BMJ Open ◽  
2017 ◽  
Vol 7 (9) ◽  
pp. e017199 ◽  
Author(s):  
Thomas Desautels ◽  
Ritankar Das ◽  
Jacob Calvert ◽  
Monica Trivedi ◽  
Charlotte Summers ◽  
...  
Keyword(s):  
Machine Learning ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Value Added ◽  
Secondary Outcome ◽  
Hospital Death ◽  
Care Hospital ◽  
Icu Discharge

ObjectivesUnplanned readmissions to the intensive care unit (ICU) are highly undesirable, increasing variance in care, making resource planning difficult and potentially increasing length of stay and mortality in some settings. Identifying patients who are likely to suffer unplanned ICU readmission could reduce the frequency of this adverse event.SettingA single academic, tertiary care hospital in the UK.ParticipantsA set of 3326 ICU episodes collected between October 2014 and August 2016. All records were of patients who visited an ICU at some point during their stay. We excluded patients who were ≤16 years of age; visited ICUs other than the general and neurosciences ICU; were missing crucial electronic patient record measurements; or had indeterminate ICU discharge outcomes or very early or extremely late discharge times. After exclusion, 2018 outcome-labelled episodes remained.Primary and secondary outcome measuresArea under the receiver operating characteristic curve (AUROC) for prediction of unplanned ICU readmission or in-hospital death within 48 hours of first ICU discharge.ResultsIn 10-fold cross-validation, an ensemble predictor was trained on data from both the target hospital and the Medical Information Mart for Intensive Care (MIMIC-III) database and tested on the target hospital’s data. This predictor discriminated between patients with the unplanned ICU readmission or death outcome and those without this outcome, attaining mean AUROC of 0.7095 (SE 0.0260), superior to the purpose-built Stability and Workload Index for Transfer (SWIFT) score (AUROC=0.6082, SE 0.0249; p=0.014, pairwise t-test).ConclusionsDespite the inherent difficulties, we demonstrate that a novel machine learning algorithm based on transfer learning could achieve good discrimination, over and above that of the treating clinicians or the value added by the SWIFT score. Accurate prediction of unplanned readmission could be used to target resources more efficiently.

scholarly journals Electromyographic activity of preterm newborns in the kangaroo position: a cohort study

BMJ Open ◽  
2014 ◽  
Vol 4 (10) ◽  
pp. e005560 ◽  
Author(s):  
Rafael Moura Miranda ◽  
José Eulálio Cabral Filho ◽  
Kaísa Trovão Diniz ◽  
Geisy Maria Souza Lima ◽  
Danilo de Almeida Vasconcelos
Keyword(s):  
Cohort Study ◽  
Tertiary Care ◽  
Secondary Outcome ◽  
Vertical Position ◽  
Electromyographic Activity ◽  
Term Infants ◽  
Skin Contact ◽  
Child Hospital ◽  
Skin To Skin ◽  
Preterm Newborns

ObjectiveTo compare the electromyographic activity of preterm newborns placed in the kangaroo position with the activity of newborns not placed in this position.DesignA cohort study.SettingA Kangaroo Unit sector and a Nursery sector in a secondary and tertiary care at a mother-child hospital in Recife, Brazil.ParticipantsPreterm infants of gestational age 27–34 weeks (n=38) and term infants (n=39).Primary and secondary outcome measuresSurface electromyography was used to investigate muscle activity in the brachial biceps at rest. 3 groups were designed: (1) preterm newborns in the kangaroo position (PT-KAN), where the newborn remains in a vertical position, lying face down, with limbs flexed, dressed in light clothes, maintaining skin-to-skin contact with the adult's thorax. Her electromyographic activity was recorded at 0 h (immediately before starting this position), and then at 48 h after the beginning of the position (but newborns were kept in the kangaroo position for 8–12 h per day) and at term equivalent age (40±1 weeks); (2) preterm newborns not in the kangaroo position (PT-NKAN), in which measurements were made at 0 h and 48 h; and (3) term newborns (T), in which measurements were made at 24 h of chronological age.ResultsThe Root Mean Square (RMS) values showed significant differences among groups (F(5,108)=56.69; p<0.001). The multiple comparisons showed that RMS was greater at 48 h compared to 0 h in the preterm group in the kangaroo position, but not in the group not submitted in the kangaroo position. The RMS in the term equivalent aged group in the kangaroo position was also greater when compared with those in the term group.ConclusionsThe kangaroo position increases electromyographic activity in the brachial biceps of preterm newborns and those who have reached the age equivalent to term.

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