Impact of a Prolonged COVID-19 Lockdown on Patterns of Admission, Mortality and Performance Indicators in a Cardiovascular Intensive Care Unit

Background The effects of an early and prolonged lockdown during the COVID-19 pandemic on cardiovascular intensive care units is not well established. This study analyses patterns of admission, mortality and performance Indicators in a cardiovascular intensive care unit before and during the Argentine lockdown in the COVID-19 pandemic. Methods This is a retrospective observational cross-sectional study of all consecutive patients aged 18 years or more admitted to the Cardiac Intensive Care Unit at a high-volume reference hospital in Buenos Aires, Argentina comparing hospitalization rates, primary causes of admission, inpatient utilisation indicators, pharmacy supplies expenditures, and in-hospital mortality between March 5 and July 31, 2020 with two corresponding control periods in 2019 and 2018. Results We included 722 patients [mean age of 61.6 (SD 15.5) years; 237 (32.8%)] were females. Overall hospitalisations dropped 53.2% (95%CI: 45.3, 61.0%) from 295.5 patients/year over the periods 2018/2019 to 137 patients in 2020. Cardiovascular disease-related admissions dropped 59.9%, while admission for noncardiac causes doubled its prevalence from 9.6% over the periods 2018/2019 to 22.6% in the study period (P<0.001). In the period 2020, the bed occupancy rate fell from 82.2% to 77.4%, and the bed turnover rate dropped 50% from 7.88 to 3.91 monthly discharges/bed. The average length of stay doubled from 3.26 to 6.75 days, and the turnover interval increased from 3.8 to 8.39 days in 2020. Pharmacy supplies expenditures per discharge increased 134% along with a rise in antibiotics usage from 6.5 to 11.4 vials/ampoules per discharge (P<0.02). Overall mortality increased from 7% (n=41) to 13.9% (n=19) (P=0.008) at the expense of noncardiac related admissions (3.6% to 19.4%, P=0.01). Conclusions This study found a significant reduction in overall and cardiovascular disease-related causes of admission to the cardiac intensive care unit, worse performance indicators and increased in-hospital mortality along the first five months of the early and long-lasting COVID-19 lockdown in Argentina. These results highlight the need to foster public awareness concerning the risks of avoiding hospital attendance. Moreover, health systems should follow strict screening protocols to prevent potential biases in the admission of patients with critical conditions unrelated to the COVID-19 pandemic.

Echocardiography and thoracic ultrasound

For the emergency management of cardiovascular disorders, echocardiography and thoracic ultrasound are indispensable imaging techniques at the bedside. In the intensive care environment, crucial questions, such as left and right ventricular function, valvular heart disease, volume status, aortic disease, cardiac infection, pleural effusion, pulmonary oedema, pneumothorax, and many others, can be sufficiently and reliably answered by using these techniques; in fact, it is almost impossible to manage patients with acute severe haemodynamic impairment reasonably well without prompt and repeated access to echocardiography. This is confirmed by the prominent place that echocardiography has in the guideline-based diagnosis and treatment of all major cardiovascular emergencies, from acute heart failure to acute coronary syndrome to pulmonary embolism, etc. Moreover, it is the ideal tool to follow up the patient, since repeat examinations pose no risk to the patient and demand relatively little logistics and resources. To benefit from the wealth of information that echocardiography and thoracic ultrasound can provide, modern equipment (including a transoesophageal probe) and systematic training of echocardiographers must be ensured. The availability of prompt and experienced echocardiography and thoracic ultrasound services at all times is fundamental for sound contemporary cardiovascular intensive care.

Implementing a Goal-Directed Therapy Protocol for Fluid Resuscitation in the Cardiovascular Intensive Care Unit

Background Balancing fluid administration and titration of vasoactive medications is critical to preventing postoperative complications in cardiac surgical patients. Objective To evaluate the impact of implementing a goal-directed therapy protocol in the cardiovascular intensive care unit on total intravenous fluids administered on the day of surgery, rates of acute kidney injury, and hospital length of stay. Methods A fluid resuscitation protocol using dynamic assessment of fluid responsiveness with stroke volume index was developed, and nurses were prepared for its implementation using simulation training. Results After implementation of the new protocol, the total amount of intravenous fluids administered on the day of surgery was significantly reduced (P = .003). There were no significant changes in hospital length of stay (P = .83) or rates of acute kidney injury (P = .86). There were significant increases in nurses’ knowledge of (P < .001) and confidence in (P < .001) fluid resuscitation and titration of vasoactive medications after simulation training. Conclusions Use of a fluid resuscitation protocol resulted in a reduction in the amount of intravenous fluids administered on the day of surgery. The simulation training increased nurses’ knowledge of and confidence in fluid resuscitation and titration of vasoactive medications.