Outcomes of COVID-19 patients treated with continuous positive airway pressure outside ICU

AimWe aim at characterising a large population of Coronavirus 19 (COVID-19) patients with moderate-to-severe hypoxemic acute respiratory failure (ARF) receiving CPAP outside intensive care unit (ICU), and ascertaining whether the duration of CPAP application increased the risk of mortality for patients requiring intubation.MethodsIn this retrospective, multicentre cohort study, we included COVID-19 adult patients, treated with CPAP outside ICU for hypoxemic ARF from March 1st to April 15th, 2020. We collected demographic and clinical data, including CPAP therapeutic goal, hospital length of stay (LOS), and 60-day in-hospital mortality.ResultsThe study includes 537 patients with a median age of 69 (IQR, 60–76) years. Males were 391 (73%). According to predefined CPAP therapeutic goal, 397 (74%) patients were included in full treatment subgroup, and 140 (26%) in the do-not intubate (DNI) subgroup. Median CPAP duration was 4 (IQR, 1–8) days, while hospital LOS 16 (IQR, 9–27) days. Sixty-day in-hospital mortality was overall 34% (95%CI, 0.304–0.384), and 21% (95%CI, 0.169–0.249) and 73% (95%CI, 0.648–0.787) for full treatment and DNI subgroups, respectively. In the full treatment subgroup, in-hospital mortality was 42% (95%CI, 0.345–0.488) for 180 (45%) CPAP failures requiring intubation, while 2% (95%CI, 0.008–0.035) for the remaining 217 (55%) patients who succeeded. Delaying intubation was associated with increased mortality [HR, 1.093 (95%CI, 1.010–1.184)].ConclusionsWe described a large population of COVID-19 patients treated with CPAP outside ICU. Intubation delay represents a risk factor for mortality. Further investigation is needed for early identification of CPAP failures.

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Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

BMJ Open ◽

10.1136/bmjopen-2017-018190 ◽

2018 ◽

Vol 8 (3) ◽

pp. e018190 ◽

Cited By ~ 18

Author(s):

Marcel Émond ◽

Valérie Boucher ◽

Pierre-Hugues Carmichael ◽

Philippe Voyer ◽

Mathieu Pelletier ◽

...

Keyword(s):

Older Adults ◽

Emergency Department ◽

Cohort Study ◽

Length Of Stay ◽

Hospital Length ◽

Cognitive Status ◽

Hospital Ward ◽

Hospital Length Of Stay ◽

Multicentre Cohort Study ◽

Multicentre Cohort

ObjectiveWe aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment.DesignThis is a prospective observational multicentre cohort study (March–July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward.SettingThe study took place in four Canadian EDs.Participants338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent.Main outcome(s) and measure(s)The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes.ResultsMean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5–47.9) hours and hospital LOS was 146.6 (75.2–267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient.ConclusionsAn incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

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Outcomes of Neutropenic Patients with Clostridium difficile Infection

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.950 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s339-s340

Author(s):

Roopali Sharma ◽

Deepali Dixit ◽

Sherin Pathickal ◽

Jenny Park ◽

Bernice Lee ◽

...

Keyword(s):

Clostridium Difficile ◽

Length Of Stay ◽

Hospital Mortality ◽

Treatment Failure ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Hospital Length ◽

Hospital Length Of Stay ◽

End Point ◽

Neutropenic Patients

Background: Data from Clostridium difficile infection (CDI) in neutropenic patients are still scarce. Objective: To assess outcomes of CDI in patients with and without neutropenia. Methods: The study included a retrospective cohort of adult patients at 3 academic hospitals between January 2013 and December 2017. The 2 study arms were neutropenic patients (neutrophil count <500/mm3) and nonneutropenic patients with confirmed CDI episodes. The primary outcome evaluated the composite end point of all-cause in-hospital mortality, intensive care unit (ICU) admissions, and treatment failure at 7 days. The secondary outcome evaluated hospital length of stay. Results: Of 962 unique cases of CDI, 158 were neutropenic (59% men) and 804 were nonneutropenic (46% men). The median age was 57 years (IQR, 44–64) in the neutropenic group and 68 years (IQR, 56–79) in the nonneutropenic group. The median Charlson comorbidity score was 5 (IQR, 3–7.8) and 4 (IQR, 3–5) in the neutropenic and nonneutropenic groups, respectively. Regarding severity, 88.6% versus 48.9% were nonsevere, 8.2% versus 47% were severe, and 3.2% versus 4.1% were fulminant in the neutropenic and nonneutropenic groups, respectively. Also, 63% of patients (60.9% in nonneutropenic, 65.2% in neutropenic) were exposed to proton-pump inhibitors. A combination CDI treatment was required in 53.2% of neutropenic patients and 50.1% of nonneutropenic patients. The primary composite end point occurred in 27% of neutropenic patients versus 22% of nonneutropenic patients (P = .257), with an adjusted odds ratio of 1.30 (95% CI, 0.84–2.00). The median hospital length of stay after controlling for covariates was 21.3 days versus 14.2 days in the neutropenic and nonneutropenic groups, respectively (P < .001). Complications (defined as hypotension requiring vasopressors, ileus, or bowel perforation) were seen in 6.0% of the nonneutropenic group and 4.4% of the neutropenic group (P = .574), with an adjusted odds ratio of 0.61 (95% CI, 0.28–1.45). Conclusions: Neutropenic patients were younger and their cases were less severe; however, they had lower incidences of all-cause in-hospital mortality, ICU admissions, and treatment failure. Hospital length of stay was significantly shorter in the neutropenic group than in the nonneutropenic group.Funding: NoneDisclosures: None

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562. Tocilizumab for the Treatment of Severe COVID-19: A Retrospective, Multi-Center, Case-Matched Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.756 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S346-S346

Author(s):

Sarah Norman ◽

Sara Jones ◽

David Reeves ◽

Christian Cheatham

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Hospital Mortality ◽

Primary Outcome ◽

Fungal Infections ◽

Hospital Length ◽

Hospitalized Patients ◽

Hospital Length Of Stay ◽

Matched Design ◽

Median Hospital

Abstract Background At the time of this writing, there is no FDA approved medication for the treatment of COVID-19. One medication currently under investigation for COVID-19 treatment is tocilizumab, an interleukin-6 (IL-6) inhibitor. It has been shown there are increased levels of cytokines including IL-6 in severe COVID-19 hospitalized patients attributed to cytokine release syndrome (CRS). Therefore, inhibition of IL-6 receptors may lead to a reduction in cytokines and prevent progression of CRS. The purpose of this retrospective study is to utilize a case-matched design to investigate clinical outcomes associated with the use of tocilizumab in severe COVID-19 hospitalized patients. Methods This was a retrospective, multi-center, case-matched series matched 1:1 on age, BMI, and days since symptom onset. Inclusion criteria included ≥ 18 years of age, laboratory confirmed positive SARS-CoV-2 result, admitted to a community hospital from March 1st – May 8th, 2020, and received tocilizumab while admitted. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, total mechanical ventilation days, mechanical ventilation mortality, and incidence of secondary bacterial or fungal infections. Results The following results are presented as tocilizumab vs control respectively. The primary outcome of in-hospital mortality for tocilizumab (n=26) vs control (n=26) was 10 (38%) vs 11 (42%) patients, p=0.777. The median hospital length of stay for tocilizumab vs control was 14 vs 11 days, p=0.275. The median days of mechanical ventilation for tocilizumab (n=21) vs control (n=15) was 8 vs 7 days, p=0.139, and the mechanical ventilation mortality was 10 (48%) vs 9 (60%) patients, p=0.463. In the tocilizumab group, for those expired (n=10) vs alive (n=16), 10 (100%) vs 7 (50%) patients respectively had a peak ferritin > 600 ng/mL, and 6 (60%) vs 8 (50%) patients had a peak D-dimer > 2,000 ng/mL. The incidence of secondary bacterial or fungal infections within 7 days of tocilizumab administration occurred in 5 (19%) patients. Conclusion These findings suggest that tocilizumab may be a beneficial treatment modality for severe COVID-19 patients. Larger, prospective, placebo-controlled trials are needed to further validate results. Disclosures Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)

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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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132 Physical Function Comparison of Acutely Unwell COVID-Negative Older Adults Pre-Pandemic and Through-Pandemic; “Covid-Protected”

Age and Ageing ◽

10.1093/ageing/afab030.93 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

S Ritchie ◽

C Snape ◽

N Triteos ◽

R Vamadevan ◽

L Olesk ◽

...

Keyword(s):

Older Adults ◽

Mortality Rate ◽

Hospital Mortality ◽

Physical Function ◽

Gait Speed ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Ethical Review ◽

Short Period ◽

Elderly Mobility

Abstract Introduction The risk of severe morbidity after COVID-19 infection is high in older adults (Lithander et al, 2020). Subsequent responsive UK Government guidance for older adults included self-isolation during the pandemic. It is therefore hypothesised that during the pandemic older adults are inadvertently deconditioned due to iatrogenic factors such as inactivity, social isolation, hospital-avoidance and malnutrition, and present with reduced resilience to illness and lower levels of function. The OPU continued to admit COVID-negative, or recently termed “COVID-protected”, patients throughout the pandemic. Data captured prior to, and during the COVID-19 pandemic has been compared to explore the implications on older adults, and elicit whether they are protected from the consequences of the pandemic? Method Demographic and physical function data (average 6 m gait-speed, Elderly Mobility Scale) were captured pre- and through-pandemic for all patients admitted to a COVID-negative OPU ward over a one month period. Ethical review was provided through local Trust governance process. Results Pre-pandemic 2019 (n = 67, mean(±SD) age 82.7(±8.2) years, 61%, hospital length-of-stay (LOS) 7.9(±7.3) days, hospital mortality-rate 7.2%) and through-pandemic 2020 (n = 73, 83.1(±8.3) years, 59%♀, LOS 9.0(±9.1) days, hospital mortality-rate 7.5%) data were captured during July 2019 and May 2020 respectively. There were no between-group differences in age [t(−.313) = 138, p = 0.755], gender [X2, 1 df, p = 0.782], LOS [t(0.78) = 134, p = 0.44], or hospital mortality-rate [X2 1 df, p = 0.96]. Through-pandemic patients had a significantly slower 6 m gait-speed (0.11(±0.05) m.s-1) than pre-pandemic (0.16(±0.24) m.s-1); [t(2.74) = 93, p = 0.007] and lower median (IQR) Elderly Mobility Scale (4(6 IQR) vs 9 (12 IQR) [u = 866, p = 0.015]). Conclusion Our data indicates this relatively short period of self-isolation might have significant implications on the physical function of older adults. The likely mechanism is iatrogenic deconditioning. Critical Public Health and policy responses are required to mitigate these unforeseen risks by deploying prehabilitative counter-measures and accurately targeted hospital and community rehabilitation.

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Effective Antibiotic Conservation by Emergency Antimicrobial Stewardship During a Drug Shortage

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2016.289 ◽

2016 ◽

Vol 38 (3) ◽

pp. 356-359 ◽

Cited By ~ 5

Author(s):

Kevin Hsueh ◽

Maria Reyes ◽

Tamara Krekel ◽

Ed Casabar ◽

David J. Ritchie ◽

...

Keyword(s):

Length Of Stay ◽

Hospital Mortality ◽

Antimicrobial Stewardship ◽

Hospital Length ◽

Antimicrobial Drug ◽

Hospital Length Of Stay ◽

Antimicrobial Stewardship Program ◽

Drug Shortage ◽

Stewardship Program ◽

Formulary Restriction

We present the first description of an antimicrobial stewardship program (ASP) used to successfully manage a multi-antimicrobial drug shortage. Without resorting to formulary restriction, meropenem utilization decreased by 69% and piperacillin-tazobactam by 73%. During the shortage period, hospital mortality decreased (P=.03), while hospital length of stay remained unchanged.Infect Control Hosp Epidemiol 2017;38:356–359

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External validation of the quick Sequential Organ Failure Assessment score for mortality and bacteraemia risk evaluation in Japanese patients undergoing haemodialysis: a retrospective multicentre cohort study

BMJ Open ◽

10.1136/bmjopen-2018-028856 ◽

2019 ◽

Vol 9 (7) ◽

pp. e028856

Author(s):

Hiroki Nishiwaki ◽

Sho Sasaki ◽

Takeshi Hasegawa ◽

Fumihiko Sasai ◽

Hiroo Kawarazaki ◽

...

Keyword(s):

Cohort Study ◽

Blood Culture ◽

Hospital Mortality ◽

Secondary Care ◽

Tertiary Care ◽

External Validation ◽

Multicentre Cohort Study ◽

Failure Assessment ◽

Qsofa Score ◽

Multicentre Cohort

ObjectivesWe aimed to examine the validity of the quick Sequential Organ Failure Assessment (qSOFA) score for mortality and bacteraemia risk assessment in Japanese haemodialysis patients.DesignThis is a retrospective multicentre cohort study.SettingThe six participating hospitals are tertiary-care institutions that receive patients on an emergency basis and provide primary, secondary and tertiary care. The other participating hospital is a secondary-care institution that receives patients on an emergency basis and provides both primary and secondary care.ParticipantsThis study included haemodialysis outpatients admitted for bacteraemia suspicion, who had blood drawn for cultures within 48 hours of their initial admission.Primary and secondary outcome measuresThe primary outcome measure was overall in-hospital mortality. Secondary outcomes included 28-day in-hospital mortality and the incidence of bacteraemia diagnosed based on blood culture findings. The discrimination, calibration and test performance of the qSOFA score were assessed. Missing data were handled using multiple imputation.ResultsAmong the 507 haemodialysis patients admitted with bacteraemia suspicion between August 2011 and July 2013, the overall in-hospital mortality was 14.6% (74/507), the 28-day in-hospital mortality was 11.1% (56/507) and the incidence of bacteraemia, defined as a positive blood culture, was 13.4% (68/507). For predicting in-hospital mortality among haemodialysis patients, the area under the receiver operating characteristic curve was 0.61 (95% CI 0.56–0.67) for a qSOFA score ≥2. The Hosmer-Lemeshow χ2statistics for the qSOFA score as a predictor of overall and 28-day in-hospital mortality were 5.72 (p=0.02) and 7.40 (p<0.01), respectively.ConclusionOn external validation, the qSOFA score exhibited low diagnostic accuracy and miscalibration for in-hospital mortality and bacteraemia among haemodialysis patients.

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Impact of Changes in Serum Calcium Levels on In-Hospital Mortality

Medicina ◽

10.3390/medicina56030106 ◽

2020 ◽

Vol 56 (3) ◽

pp. 106 ◽

Cited By ~ 3

Author(s):

Charat Thongprayoon ◽

Wisit Cheungpasitporn ◽

Panupong Hansrivijit ◽

Juan Medaura ◽

Api Chewcharat ◽

...

Keyword(s):

Hospital Mortality ◽

Serum Calcium ◽

Reference Group ◽

Kidney Injury ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Absolute Difference ◽

Systemic Level ◽

Patient Database ◽

Independent Association

Background and objectives: Calcium concentration is strictly regulated at both the cellular and systemic level, and changes in serum calcium levels can alter various physiological functions in various organs. This study aimed to assess the association between changes in calcium levels during hospitalization and mortality. Materials and Methods: We searched our patient database to identify all adult patients admitted to our hospital from January 1st, 2009 to December 31st, 2013. Patients with ≥2 serum calcium measurements during the hospitalization were included. The serum calcium changes during the hospitalization, defined as the absolute difference between the maximum and the minimum calcium levels, were categorized into five groups: 0–0.4, 0.5–0.9, 1.0–1.4, 1.5–1.9, and ≥2.0 mg/dL. Multivariable logistic regression was performed to assess the independent association between calcium changes and in-hospital mortality, using the change in calcium category of 0–0.4 mg/dL as the reference group. Results: Of 9868 patients included in analysis, 540 (5.4%) died during hospitalization. The in-hospital mortality progressively increased with higher calcium changes, from 3.4% in the group of 0–0.4 mg/dL to 14.5% in the group of ≥2.0 mg/dL (p < 0.001). When adjusted for age, sex, race, principal diagnosis, comorbidity, kidney function, acute kidney injury, number of measurements of serum calcium, and hospital length of stay, the serum calcium changes of 1.0–1.4, 1.5–1.9, and ≥2.0 mg/dL were significantly associated with increased in-hospital mortality with odds ratio (OR) of 1.55 (95% confidence interval (CI) 1.15–2.10), 1.90 (95% CI 1.32–2.74), and 3.23 (95% CI 2.39–4.38), respectively. The association remained statistically significant when further adjusted for either the lowest or highest serum calcium. Conclusion: Larger serum calcium changes in hospitalized patients were progressively associated with increased in-hospital mortality.

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The influence of volume and intensive care unit organization on hospital mortality in patients admitted with severe sepsis: a retrospective multicentre cohort study

Critical Care ◽

10.1186/cc5727 ◽

2007 ◽

Vol 11 (2) ◽

pp. R40 ◽

Cited By ~ 64

Author(s):

Linda Peelen ◽

Nicolette F de Keizer ◽

Niels Peek ◽

Gert Scheffer ◽

Peter HJ van der Voort ◽

...

Keyword(s):

Intensive Care Unit ◽

Severe Sepsis ◽

Cohort Study ◽

Intensive Care ◽

Hospital Mortality ◽

Multicentre Cohort Study ◽

Unit Organization ◽

Multicentre Cohort

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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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