Trends in Intensive Care for Patients with COVID-19 in England, Wales and Northern Ireland

Aim: To report changes in admission rates, patient characteristics, processes of care and outcomes for all patients with COVID-19 admitted to intensive care units (ICUs) in England, Wales and Northern Ireland. Methods: Population cohort of all 10,287 patients with COVID-19 appearing in the Case Mix Programme national clinical audit from 1 February to 2 July, 2020. Analyses were stratified by time period (pre-peak, peak, post-peak) and geographical region, and multivariable regressions were used to estimate differences in 28-day mortality, adjusting for variation in patient characteristics over time. Results: Admissions to ICU peaked on 1 April, nine days after commencement of “lockdown”, and occurred simultaneously across regions. The number of patients in ICU peaked ten days later. Compared with patients admitted during the pre- and post-peak periods, patients admitted during the peak were younger and had lower levels of prior dependency but more severe respiratory and renal dysfunction. Use of invasive ventilation and renal replacement reduced over time. Twenty-eight-day mortality reduced from 43.5% (95% CI 41.6% to 45.5%) pre-peak to 34.3% (95% CI 32.3% to 36.2%) post-peak; a difference of −8.8% (95% CI: −5.2%, −12.3%) after adjusting for patient characteristics. London experienced the highest admission rate and had higher mortality during the peak period but a greater reduction in post-peak mortality. Conclusion: Observed trends suggest opposing effects of ICU strain and clinical learning. Further investigation is needed to identify modifiable system factors that could alleviate strain in future epidemics and changes in clinical practice that contributed to improved patient outcomes.

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Trends in Intensive Care for Patients with COVID-19 in England, Wales and Northern Ireland

10.20944/preprints202008.0267.v2 ◽

2020 ◽

Cited By ~ 1

Author(s):

James C Doidge ◽

Paul R Mouncey ◽

Karen Thomas ◽

Doug W Gould ◽

Paloma Ferrando-Vivas ◽

...

Keyword(s):

Intensive Care ◽

Northern Ireland ◽

Admission Rate ◽

Patient Characteristics ◽

Substantial Improvement ◽

Peak Period ◽

Processes Of Care ◽

Admission Rates ◽

The Uk ◽

Over Time

Rationale: Examining trends in patient characteristics, processes of care and outcomes, across an epidemic, provides important opportunities for learning. Objectives: To report and explore changes in admission rates, patient characteristics, processes of care and outcomes for all patients with COVID-19 admitted to intensive care units (ICUs) in England, Wales and Northern Ireland. Methods: Population cohort of 10,287 patients with COVID-19 in the Case Mix Programme national clinical audit from 1 February to 2 July, 2020. Analyses were stratified by time period (pre-peak, peak, post-peak) and geographical region. Multivariable logistic regression was used to estimate differences in 28-day mortality, adjusting for patient characteristics over time. Main results: Admissions to ICU peaked simultaneously across regions on 1 April, with ongoing admissions peaking ten days later. Compared with pre- and post-peak periods, patients admitted during the peak were slightly younger but had greater respiratory and renal dysfunction. Use of invasive ventilation and renal replacement reduced over time. Twenty-eight-day mortality reduced from 43.5% (95% CI 41.6% to 45.5%) pre-peak to 34.3% (95% CI 32.3% to 36.2%) post-peak; a difference of −8.8% (95% CI: −5.2%, −12.3%) after adjusting for patient characteristics. London experienced the highest admission rate and had higher mortality during the peak period but a greater reduction in post-peak mortality. Conclusion: This study highlights changes in patient characteristics, processes of care and outcomes, during the UK COVID-19 epidemic. After adjusting for the changes in patient characteristics and first 24-hour physiology, there was substantial improvement in 28-day mortality over the course of the epidemic.

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Epidemiology of Community-Acquired Pneumonia in Edmonton, Alberta: An Emergency Department-Based Study

Canadian Respiratory Journal ◽

10.1155/2005/672501 ◽

2005 ◽

Vol 12 (3) ◽

pp. 139-142 ◽

Cited By ~ 43

Author(s):

Thomas J Marrie ◽

Jane Q Huang

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Age Groups ◽

Admission Rate ◽

Community Acquired Pneumonia ◽

Seasonal Effect ◽

Admission Rates ◽

Younger Age ◽

Number Of Patients

Patients aged 17 years and older who presented to seven emergency departments in Edmonton, Alberta over a two-year period with community-acquired pneumonia (n=8144) were studied. The admission rates were 271/100,00 and 296/100,000 persons for year 1 and year 2 of the study, respectively. The admission rate increased with increasing age, peaking at 4639/100,000/year for those 90 years of age and older. In contrast, the percentage of patients who were admitted to an intensive care unit was highest for those in the younger age groups between 17 and 59 years of age. From 59 years of age and older, there was a progressive decline in the percentage of patients admitted to an intensive care unit, with approximately 1% of those in the 90 years and older age group admitted. A pronounced seasonal effect on the number of patients presenting to emergency department was also noted. During the winter months, there was up to a 50% increase in the number of cases compared with the summer months.

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Persistence of Pneumococcal Serotype 3 in Adult Pneumococcal Disease in Hong Kong

Vaccines ◽

10.3390/vaccines9070756 ◽

2021 ◽

Vol 9 (7) ◽

pp. 756

Author(s):

Reema Subramanian ◽

Veranja Liyanapathirana ◽

Nilakshi Barua ◽

Rui Sun ◽

Maggie Haitian Wang ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Pneumococcal Disease ◽

Disease Burden ◽

Patient Characteristics ◽

Adult Vaccination ◽

Pneumococcal Serotype ◽

Pneumococcal Immunisation ◽

Microbroth Dilution ◽

Over Time

The epidemiology of hospitalised pneumococcal disease in adults following the introduction of universal childhood pneumococcal immunisation in 2009 was assessed. Culture-confirmed Streptococcus pneumoniae (SP) from adults hospitalised between 2009 to 2017 were examined. The cases were categorised into invasive pneumococcal disease (IPD) and pneumonia (bacteraemic, non-bacteraemic, and that associated with other lung conditions). The isolates were serotyped and antimicrobial susceptibilities were determined by microbroth dilution. Patient characteristics, comorbidities, and outcomes were analysed. Seven hundred and seventy-four patients (mean age, 67.7 years, SD ± 15.6) were identified, and IPD was diagnosed in 110 (14.2%). The most prevalent serotype, 19F, was replaced by serotype 3 over time. Penicillin and cefotaxime non-susceptibilities were high at 54.1% and 39.5% (meningitis breakpoints), 19.9% and 25.5% (non-meningitis breakpoints), respectively. The overall 30-day mortality rate was 7.8% and 20.4% for IPD. Age ≥ 75 years (OR:4.6, CI:1.3–17.0, p < 0.02), presence of any complications (OR:4.1, CI:1.02–16.3, p < 0.05), pleural effusion (OR:6.7, CI:1.2–39.4, p < 0.03) and intensive care unit (ICU) admission (OR:9.0, CI:1.3–63.4, p < 0.03) were independent predictors of 30-day mortality. Pneumococcal disease by PCV 13 covered serotypes; in particular, 19F and 3 are still prominent in adults. Strengthening targeted adult vaccination may be necessary in order to reduce disease burden.

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Drug Use in a Surgical Intensive Care Unit

Drug Intelligence & Clinical Pharmacy ◽

10.1177/106002808602001002 ◽

1986 ◽

Vol 20 (10) ◽

pp. 752-756 ◽

Cited By ~ 11

Author(s):

Joseph F. Dasta

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Drug Use ◽

Patient Characteristics ◽

Surgical Intensive Care Unit ◽

Close Monitoring ◽

Surgical Intensive Care ◽

Drug Usage ◽

Time Period ◽

Short Time

A retrospective review of drug usage in 180 patients admitted to a surgical intensive care unit was conducted. The average stay was three days and the total and daily number of drugs averaged 7.6 and 5.6, respectively. The most common drug class used was antibiotics, with cefazolin being the most commonly used antibiotic. Other commonly used drugs include analgesics, diuretics, H2-antagonists, vasoactive drugs and inotropes, antacids, and antiarrhythmics. This study indicates that patients admitted to a surgical intensive care unit are exposed to a variety of potent drugs, often given in combination over a short time period. Although further studies are needed to delineate specific aspects of drug use and patient characteristics, this study suggests that there is a need for close monitoring of drug therapy in these patients with special attention to reduction of drug costs.

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Low ninety-day re-admission rates after emergency and elective laparoscopic cholecystectomy in a district general hospital

Annals of The Royal College of Surgeons of England ◽

10.1308/003588410x12664192075053 ◽

2010 ◽

Vol 92 (4) ◽

pp. 307-310 ◽

Cited By ~ 8

Author(s):

Sue K Down ◽

Marko Nicolic ◽

Hibba Abdulkarim ◽

Nick Skelton ◽

Adrian H Harris ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

General Hospital ◽

Admission Rate ◽

Economic Cost ◽

District General Hospital ◽

Patient Characteristics ◽

True Incidence ◽

Admission Rates ◽

Emergency Procedures ◽

Elective Laparoscopic Cholecystectomy

INTRODUCTION Re-admission rate following laparoscopic cholecystectomy is currently defined as within 30 days of the initial operation. This may underestimate the true incidence and financial cost of postoperative morbidity. This study aimed to analyse re-admissions within 90 days of elective and emergency laparoscopic cholecystectomy at a district general hospital, and to compare outcomes to larger teaching centres. PATIENTS AND METHODS We undertook a retrospective analysis of all patients re-admitted within 90 days of laparoscopic cholecystectomy during an 18-month period (June 2006 to December 2007). Patient characteristics, details of the primary operation, and reasons for re-admission were identified, and a comparison of re-admissions following elective versus emergency procedures was performed. RESULTS A total of 326 laparoscopic cholecystectomies were performed during the 18-month period (246 elective, 80 emergency). No operations required conversion to an open procedure. Twenty-five patients were re-admitted within 90 days of their operation, of whom only 14 had complications directly related to their surgery (overall re-admission rate 4.3%). There was no statistical difference in re-admission rate or cause of re-admission between elective and emergency procedures. However, the mean time to re-admission following elective procedures was significantly longer (36 days; P = 0.0003). CONCLUSIONS Re-admission rates at our district general hospital are comparable to those reported by larger teaching centres. Current 30-day re-admission data may significantly underestimate morbidity rates and socio-economic cost following elective laparoscopic cholecystectomy.

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Transfusion Practice in the Intensive Care Unit: A Ten-Year Analysis.

Blood ◽

10.1182/blood.v114.22.2111.2111 ◽

2009 ◽

Vol 114 (22) ◽

pp. 2111-2111

Author(s):

Giora Netzer ◽

Xinggang Liu ◽

Anthony Harris ◽

Bennett Edelman ◽

John Hess ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Single Unit ◽

Medical Center ◽

Transfusion Practice ◽

Transfusion Strategy ◽

Time Period ◽

The Mean ◽

Restrictive Transfusion Strategy ◽

Over Time

Abstract Abstract 2111 Poster Board II-88 Introduction: Since the 1990s, there has been increasing evidence to support a restrictive transfusion strategy in the intensive care unit. While prior studies have evaluated transfusion practice in the short term, the impact of the Transfusion Requirements in Critical Care (TRICC) recommendations and related guidelines over the course of a prolonged time period has not been evaluated. We describe and assess transfusion practice during the period 1997-2007 in a large, academic medical center medical intensive care unit (MICU). Patients and Methods: We conducted a single center, retrospective, observational study of 3533 patients with single admissions to the University of Maryland Medical Center MICU between 1997 and 2007. Patients with acute coronary syndromes, hemorrhage and hemoglobinopathies were excluded, as were patients less than 13 years of age. Baseline characteristics of transfused and non-transfused patients were compared. We described the mean MICU admission hemoglobin (Hgb) levels, percentages of patients transfused as a whole and by MICU admission Hgb strata, mean pre-transfusion Hgb levels in transfused patients and nadir Hgb in the non-transfused, proportion of patients transfused with pre-transfusion Hgb<7.0 g/dL, mean number of units transfused in patients receiving transfusion, and the proportion of single unit transfusion episodes over time. Changes over 9 intervals of time between 1997-2007 were assessed with linear or logistic regression. Results: MICU admission Hgb did not change in any important way over the study period (-0.022 g/dL per interval, 95% CI -0.0051–0.007, p=0.13). The proportion of transfused patients decreased over time from 31.0% in 1997-1998 to 18.0% in 2006-2007 (p<0.001). The strongest and most consistent evidence of a steep decline in percentage of patients transfused was in the first half of the decade studied, among patients whose MICU admission Hgb levels were ≥7.0 g/dL and <10.0 g/dL. Among patients receiving transfusion, the mean pre-transfusion Hgb decreased over time from 7.9±1.3 to 7.3±1.3 g/dL (p<0.001). The nadir Hgb in non-transfused patients also decreased from a mean Hgb 11.2±2.2 g/dL in 1997-1999 to Hgb10.4±2.3 in 2006–2007 (p<0.001). The mean number of units transfused decreased during this time period from 4.3 to 3.0 units per patient transfused (p<0.001). The proportion of patients transfused at Hgb<7.0 g/dL increased by an absolute increment of 3.2% (95%CI: 2.1-4.3%) per interval (p<0.001), as did the proportion of single unit transfusions during the first transfusion episode with an absolute proportion of 1.4% per year (95% CI:0.2-2.6%, p=0.03) from 40.2% in 1997-1998 to 53.1% in 2006-2007. Conclusions: Between 1997 and 2007, important and sustained changes have occurred in MICU physician transfusion behavior, with overall reductions in the proportion of patients transfused, mean pre-transfusion Hgb level, and nadir Hgb level in patients who were not transfused. While physicians moved closer to the restrictive transfusion strategy reflected in guidelines and tested in a multi-center clinical trial, there may still be room for improvement. Disclosures: No relevant conflicts of interest to declare.

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Frequency of Emergency Department Visits for Sickle Cell Disease Vaso-Occlusive Crisis and Its Contribution to Hospital Admission Rates

Blood ◽

10.1182/blood.v126.23.5569.5569 ◽

2015 ◽

Vol 126 (23) ◽

pp. 5569-5569

Author(s):

Patrick Loeffler ◽

Taylor Mueller ◽

Abdullah Kutlar ◽

Robert Gibson ◽

LaShon Sturgis ◽

...

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Hospital Admission ◽

Admission Rate ◽

Cell Disease ◽

Admission Rates ◽

Time Period ◽

Number Of Visits ◽

The Difference ◽

First Time

Abstract Background: Patients with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED). To improve and increase consistency of care patients with uncomplicated VOC, are treated in the Emergency Department Observation Unit (EDOU) where they are treated with an individualized protocol-based pathway. EDOUs have been shown to be effective in meeting treatment guidelines and reducing hospital admission. Objective: This study examines the admission rates of individuals with SCD stratified by frequency of presentation at the EDOU. Methods: A retrospective review of an ED database was completed to explore the relationship between EDOU utilization and admission rate for patients with uncomplicated VOC. All patient records meeting pathway inclusion criteria for uncomplicated VOC during the time period September 2013 through May 2015 were included in the study. Visits were first associated with individual patients. Then, based on the number of visits per time period, patients were categorized as high users, moderate users, or low users. Categorization was done using the number of visits during the first, 12-month period (9/11/13 - 9/10/14), or the second, nine-month period (9/10/14 - 5/31/15). Adaptations to the categorization scheme for the nine-month time period were as follows. Low users were patients that had no more than one visit in either the first or second time period; moderate users were patients with two or three visits in the first time period or two visits in the second; high users were patients with four or more visits in the first time period, or three or more visits in the second time period. Admission rates were calculated as percentages of visits to the EDOU. Rates of admission for high, middle, and low users were compared using an unpaired, one-tailed Student's t-test. This study was approved by expedited review by the institution's Institutional Review Board (IRB). Results: A total of 727 visits for 154 patients were included in the analysis. High users (n=44) had a total of 539 visits and an average patient admission rate of 22% (n=118). Moderate users (n=49) had a total of 108 visits and an admission rate of 31% (n=33). Low users (N=61) had a total of 80 visits and an admission rate of 36% (n=29). The difference between the number of high user admissions and low user admissions was significant (p<0.01) as was the difference between the number of moderate-user visits and the number of high-user visits (p=0.04). The difference between the number of moderate and low user admissions was not significant (p=0.14). Conclusion: This study found that the difference in the number of admissions between high and low users and between high and moderate users was significant. The findings provide support for the value of the EDOU in reducing unnecessary hospital admissions. These findings also raise important questions regarding the phenotypic expression of pain in SCD and the availability of care. Although the criteria for categorization of patients in this study was limited and the time periods unequal the results suggest different patterns of personal response to pain and treatment seeking. It is unknown how these groups may be different in regards to access to care, treatment preferences, self-care practices, or severity of disease. It can be hypothesized from these results that there may be two different patterns of care seeking with some patients only using the EDOU when crisis is severe (low users) and other patients (high users) using the EDOU as part of their regular pain treatment strategy. To address these questions it is necessary to further examine the differences between these groups to look for explanations that can address increased utilization of the EDOU among some patients. Disclosures No relevant conflicts of interest to declare.

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824. Isolation Rounding - Enforcing Existing Isolation Policies to Conserve Personal Protective Equipment

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1013 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S454-S454

Author(s):

Joshua K Schaffzin ◽

Stephanie Herber ◽

Nicole Kneflin ◽

Matthew Frazier ◽

Alyssa Paolella ◽

...

Keyword(s):

Intensive Care Unit ◽

Personal Protective Equipment ◽

Return On Investment ◽

Effective Means ◽

Pediatric Intensive Care ◽

Nurse Educator ◽

Protective Equipment ◽

Time Period ◽

Number Of Patients ◽

Over Time

Abstract Background During the COVID-19 pandemic, supplies of personal protective equipment (PPE) have been limited and sold at increased cost. Prior to the pandemic, we had initiated a project to improve PPE adherence and decrease cost by removing eligible patients from transmission based precautions (TBPs). At baseline, ordering providers are responsible for TBP utilization with orders through the electronic medical record. We observed that patients were in TBP when not indicated; remained in TBP beyond the appropriate time; and a reluctance on the part of providers to discontinue the orders. We tested the effect on TBP duration and PPE utilization house-wide through frequent review of TBP by a nurse educator with communication to providers of discontinuation opportunities. Methods From November 2019 to February 2020, all TBP orders in the pediatric intensive care unit (PICU) were reviewed intermittently. In March 2020, review was expanded to all inpatients with daily reviews in all units. Changes recommended and completed were tracked for all reviewed patients. We estimated cost of PPE in the PICU over time based on the number of patients in isolation and type of TBP utilized to determine whether our intervention resulted in reduced PPE use. Results Regular rounding in the PICU increased the proportion of patients in appropriate TBP and reduced the need to communicate with providers directly (33% vs 3% requiring intervention, Figure 1). Over the same time period, less PPE was used and PPE-related costs lowered (average total PPE cost $306.18 vs $95.15 per day, Figure 2). Less of an effect was seen when analyzing house-wide data. Figure 1 - P-chart of Percent Interventions Among Patients in TBP Figure 2 - X-chart of Total PPE Cost in the ICU Conclusion Isolation rounds is an effective means to ensure proper TBP adherence and manage PPE use appropriately. Additional study is needed to confirm a return on investment, to account for variation among units, and to sustain COVID-19-influenced gains beyond the pandemic. Disclosures All Authors: No reported disclosures

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No Change in Fireworks-Related Burn Center Admissions: A 10-Year Analysis of the Admission Rates, Treatment, and Costs

European Journal of Burn Care ◽

10.3390/ebj2010003 ◽

2021 ◽

Vol 2 (1) ◽

pp. 31-40

Author(s):

Daan Van Yperen ◽

Margriet Van Baar ◽

Suzanne Polinder ◽

Paul Van Zuijlen ◽

Gerard Beerthuizen ◽

...

Keyword(s):

Surgical Treatment ◽

Healthcare Costs ◽

Total Body Surface Area ◽

Admission Rate ◽

National Database ◽

Multicenter Cohort Study ◽

Admission Rates ◽

Burn Center ◽

The Past ◽

Number Of Patients

The aim of this study was to provide insight into the admission rate, treatment, and healthcare costs of patients with fireworks-related burns admitted to a Dutch burn center in the past 10 years. We hypothesized that, like the nationwide number of injuries, the number of patients admitted to a burn center with fireworks-related burn injuries would have decreased during the study period. In this retrospective multicenter cohort study, all patients with fireworks-related burns admitted to a Dutch burn center between 2009 and 2019 were eligible. Patients were identified from a national database and data were obtained regarding admission details, patient and injury characteristics, treatment, and healthcare costs. A total of 133 patients were included. On average, 12 patients were admitted per year. No increase or decrease was observed during the study period. The median total body surface area burned was 1% (P25–P75 0.5–2.5) and 75% of the burns were of partial thickness. Thirteen (10%) patients were admitted to the ICU and 66 (50%) underwent surgical treatment. The mean total healthcare costs across all 133 patients were estimated at €9040 (95% CI €5830 to €12,260) per patient. In contrast to the hypothesis, no increase or decrease was observed in burn center admissions over the past 10 years. Most burns were of small size, but nevertheless, all patients were admitted to a burn center and half of them underwent surgical treatment.

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Early closure of clinical trials: The experience of the National Cancer Institute of Canada Clinical Trials Group

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.6053 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. 6053-6053 ◽

Cited By ~ 1

Author(s):

W. Parulekar ◽

J. L. Pater

Keyword(s):

Clinical Trials ◽

Meta Analysis ◽

Phase Iii ◽

External Information ◽

Efficacy Analysis ◽

Time Period ◽

Number Of Patients ◽

Early Closure ◽

Phase Iii Studies ◽

Over Time

6053 Background: Phase III studies require a significant commitment on behalf of researchers and patients. Closure of a study before the originally planned number of patients have been enrolled may be due to a number of reasons such as poor accrual, information within the study that precludes continuation such as excess toxicity, an interim futility or extreme efficacy analysis or data from outside sources that render the study question obsolete. Methods: We reviewed the phase III activity of our group since inception. Reasons for early closure were classified in the following manner: accrual failure (AF), external information (EI), internal information (II). Studies were grouped by site and time period of study activation to demonstrate any trends over time. Results: 94 phase III studies led by our group were identified from our roster. Reasons for early closure are presented below. Other sites include brain with an early closure due to AF, head/neck where 1 of 3 studies closed due to AF, melanoma where 1 of 3 studies closed due to EI and sarcoma where 2 studies were successfully completed. Several of the studies that closed for accrual failure were nevertheless published either singly or as part of a meta-analysis. Conclusions: Slightly over one third of studies closed prior to achievement of the targeted sample size. Accrual failure continues to be the main cause of early study closure (27/34 or 80%) with a trend towards decreasing frequency of occurrence over time. Emerging data within or external to a study leading to study closure are important but relatively rare reasons for early closure. [Table: see text] No significant financial relationships to disclose.

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