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Author(s):  
Zainab Toteh Osakwe ◽  
Ohiro Oni-Eseleh ◽  
Gabriella Bianco ◽  
Rose Saint Fleur-Calixte

Background: We sought to examine sociodemographic and clinical characteristics present on admission to HHC associated with discharge to hospice. Methods: We used a 5% random sample of 2017 national Outcome and Assessment Information Set (OASIS) data. A Cox proportional hazards regression model was estimated for the primary outcome (discharge to hospice) to examine the associations with sociodemographic and clinical characteristics of HHC patients. Results: Among 489, 230 HHC patients, 4268 were discharged to hospice. The median (interquartile range) length of HHC stay for patients discharged to hospice care was 33 (14-78) days. Compared to White patients, Black, Hispanic, and other race, (hazard ratio [HR] = .50 [95% confidence interval, CI = .44–.57]), (HR = .53 [95% CI = .46–.62]), and (HR = .49 [95% CI = .40–.61], respectively) was associated with shorter time to discharge to hospice care. Clinical characteristics including severe dependence in activities of daily (ADL) (HR = 1.68 [95% CI = 1.01–2.78]), cognitive impairment (HR = 1.10 [95% CI = 1.01–1.20]), disruptive behavior daily (HR = 1.11 [95% CI = 1.02–1.22]), and inability to feed oneself (HR = 4.78, 95% CI = 4.30, 5.31) was associated with shorter time to discharge to hospice. Symptoms of anxiety daily (HR = 1.55 [95% CI = 1.43–1.68]), and pain daily or all the time (HR = 1.54 [95% CI = 1.43–1.64]) were associated with shorter time to discharge to hospice. Conclusions: High symptom burden, ADL dependency, and cognitive impairment on admission to HHC services was associated with greater likelihood of discharge to hospice.


Author(s):  
Tsai-Wing Ow ◽  
Evangelia Fatourou ◽  
Liane Rabinowich ◽  
Bente Pernille van den Boom ◽  
Shirjit Nair ◽  
...  

Introduction: Haemorrhage and venous thromboembolism (VTE) are recognised complications of chronic liver disease (CLD), but their prevalence and risk factors in critically ill patients is uncertain. Patients and methods: We studied a retrospective cohort of patients with CLD non-electively admitted to a specialist intensive care unit determining the prevalence and timing of major bleeding and VTE (early, present on admission/diagnosed within 48h; later diagnosed >48h post ICU admission). Associations with baseline clinical and laboratory characteristics, multi-organ failure (MOF), blood product administration and mortality were explored. Odds ratios (OR) and 95% CIs were calculated using logistic regression. Results: Of 623 patients with median age 52, bleeding (>48 hours after admission) occurred in 87 (14%) patients. Bleeding was associated with greater illness severity and increased mortality. Gastrointestinal bleeding accounted for 72% of events, secondary to portal hypertension in >90%. Procedure-related bleeding was uncommon. VTE occurred in 125 (20%) patients: Early VTE in 80 (13%) and involving the portal vein (PVT) in 85%. Later VTE affected 45 (7.2%) patients. Hepatocellular Carcinoma (HCC) and non-alcoholic liver disease were independently associated with early VTE (OR 2.79, (95% CI 1.5 -5.2) and 2.32, (1.4 -3.9) respectively), and HCC, sepsis and cryoprecipitate use with late VTE (OR 2.45, (1.11-5.43), 2.26 (1.2-4.3) and 2.60 (1.3-5.1). Conclusion: VTE was prevalent on admission to critical care and less commonly developed later. Bleeding was associated with MOF and increased mortality. Severe MOF was not associated with an increased rate of VTE which was linked with HCC, and specific etiologies of CLD.


Author(s):  
Jonathan D. Baghdadi ◽  
KC Coffey ◽  
Timileyin Adediran ◽  
Katherine E. Goodman ◽  
Lisa Pineles ◽  
...  

Background: Hospitalized patients with SARS-CoV-2 infection (COVID-19) often receive antibiotics for suspected bacterial co-infection. We estimated the incidence of bacterial co-infection and secondary infection in COVID-19 using clinical diagnoses to determine how frequently antibiotics are administered when bacterial infection is absent. Methods: We performed a retrospective cohort study of inpatients with COVID-19 present on admission to hospitals in the Premier Healthcare Database between April – June 2020. Bacterial infections were defined using ICD-10-CM diagnosis codes and associated “present on admission” coding. Co-infections were defined by bacterial infection present on admission, while secondary infections were defined by bacterial infection that developed after admission. Co-infection and secondary infection were not mutually exclusive. Results: 18.5% of 64,961 COVID-19 patients (n=12,040) presented with bacterial infection at admission, 3.8% (n=2,506) developed secondary infection after admission, and 0.9% (n=574) had both. 76.3% (n=49,551) received an antibiotic while hospitalized, including 71% of patients who had no diagnosis of bacterial infection. Secondary bacterial infection occurred in 5.7% patients receiving steroids in the first 2 days of hospitalization, 9.9% receiving tocilizumab in the first 2 days of hospitalization, and 10.3% patients receiving both. After adjusting for patient and hospital characteristics, bacterial co-infection (aRR 1.15; 95% CI, 1.11 – 1.20) and secondary infection (aRR 1.93; 95% CI, 1.82 – 2.04) were both independently associated with increased mortality. Conclusions: Though 1 in 5 inpatients with COVID-19 present with bacterial infection, secondary infections in the hospital are uncommon. Most inpatients with COVID-19 receive antibiotic therapy, including 71% of those not diagnosed with bacterial infection.


Author(s):  
Laura Sienas ◽  
Catherine M. Albright ◽  
Suzan Walker ◽  
Jane Hitti

Objective Rising maternal mortality and severe maternal morbidity (SMM) rates have drawn increasing public health attention. We evaluated patterns of SMM across the Washington State Perinatal Regional Network, in which neonatal intensive care unit (NICU) levels correlate with maternal level of care. Study Design Retrospective cohort study using de-identified patient and hospital-level rates of SMM diagnoses and procedures for all women who delivered at 58 hospitals from October 2015 to September 2016. Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System, which includes inpatient diagnosis with associated Present on Admission flags, procedure, and discharge information derived from hospital billing systems. Deliveries were stratified by having or not having SMM. For each SMM diagnosis, POA rates were tabulated. Hospital SMM rates (all SMM, transfusion only, and SMM excluding transfusion) were grouped according to their NICU level of care (critical access [CA] and 1–4). Odds ratios and 95% confidence intervals (CI) were calculated. Results Of 76,961 deliveries, 908 women (1.2%) had any SMM including 533 with transfusion only and 375 with all other SMM diagnoses/procedures. Rates of SMM were highest at level 1 and level 4 hospitals at 1.3 and 1.5%, respectively. Level 1 and CA hospitals had the highest transfusion rate (1.0%), while level 2, 3, and 4 hospitals had progressively lower rates (0.8, 0.7, and 0.5%, respectively; p < 0.01). Level 4 hospitals had the highest rate of SMM diagnoses/procedures (1.0%). Among SMM diagnoses, the percentage with POA was lowest in level 1/CA hospitals (23%) and similar across level 2, 3, and 4 hospitals (39%). Conclusion SMM diagnoses occur most frequently at the centers providing the highest level of care, likely attributable to the regional referral system. However, transfusion rates are increased in level 1/CA hospitals. Efforts to decrease SMM should focus on equipping level 1/CA hospitals with tools to decrease maternal morbidity and improve referral systems. Key Points


2021 ◽  
Vol 1 (S1) ◽  
pp. s45-s45
Author(s):  
Kelly Cawcutt ◽  
Mark Rupp ◽  
Lauren Musil

Background: The COVID-19 pandemic has challenged healthcare facilities since its discovery in late 2019. Notably, the subsequent COVID-19 pandemic has led to an increase in healthcare-acquired infections such as ventilator associated events (VAEs). Many hospitals in the United States perform surveillance for the NHSN for VAEs by monitoring mechanically ventilated patients for metrics that are generally considered to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner. Initially, a ventilator-associated condition (VAC) is met when there an increase in ventilator requirements after a period of stability or improvement. An IVAC is then met when there is evidence of an infectious process such as leukocytosis or fever and a new antimicrobial agent is started. Finally, possible ventilator-associated pneumonia (PVAP) is met when there is evidence of microbial growth or viral detection. Since the beginning of the COVID-19 pandemic, our hospital has seen an increase in VAEs, which is, perhaps, not unexpected during a respiratory illness pandemic. However, the NSHN definitions of VAE, and PVAP in particular, do not account for the novelty and nuances of COVID-19. Methods: We performed a chart review of 144 patients who had a VAE reported to the NHSN between March 1 and December 31, 2020. Results: Of the 144 patients with a VAE reported to NHSN, 39 were SARS-CoV-2 positive. Of the 39 patients, 4 patients (10.25%) met the NHSN PVAP definition due to a positive SARS-CoV-2 PCR that was collected in the prolonged viral shedding period of their illness (< 90 days). One of the four patients also had a bacterial infection in addition to their subsequent positive COVID-19 result. All these patients were admitted to the hospital with a COVID-19 diagnosis and their initial PCR swab was performed upon admission. Conclusions: We believe that the PVAP definition was inappropriately triggered by patients who were decompensating on the ventilator due to a novel respiratory virus that was present on admission. Early in the pandemic, frequent swabbing of these patients was performed to try and understand the duration of viral shedding and to determine when it would be safe to transfer patients from isolation after prolonged hospitalization. The NSHN definition should take into consideration the prolonged viral shedding period of COVID-19 and natural history of the illness, and subsequent COVID-19 testing within 90 days of an initial positive should not require classification as a hospital-acquired PVAP.Funding: NoDisclosures: None


2021 ◽  
Vol 4 (5) ◽  
pp. e218512
Author(s):  
Elizabeth W. Triche ◽  
Xin Xin ◽  
Sydnie Stackland ◽  
Danielle Purvis ◽  
Alexandra Harris ◽  
...  

Blood ◽  
2021 ◽  
Author(s):  
Hilary Baker Whitworth ◽  
Sarah E Sartain ◽  
Riten Kumar ◽  
Katherine Armstrong ◽  
Lance Ballester ◽  
...  

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is associated with thrombotic complications in adults, but the incidence of COVID-19 related thrombosis in children and adolescents is unclear. Most children with acute COVID-19 have mild disease, but coagulopathy has been associated with multisystem inflammatory syndrome in children (MIS-C), a post-infectious complication. We conducted a multicenter retrospective cohort study to determine the incidence of thrombosis in children hospitalized with COVID-19 or MIS-C and to evaluate associated risk factors. We classified patients into one of three groups for analysis: COVID-19, MIS-C, or asymptomatic SARS-CoV-2. Among a total of 853 admissions (426 COVID-19, 138 MIS-C, and 289 asymptomatic SARS-CoV-2) in 814 patients, there were 20 patients with thrombotic events (TE) (including 1 stroke). Patients with MIS-C had the highest incidence (6.5%, 9/138) versus COVID-19 (2.1%, 9/426) or asymptomatic SARS-CoV-2 (0.7%, 2/289). In patients with COVID-19 or MIS-C, the majority of thrombotic events (89%) occurred in patients ≥12 years. Patients &gt; 12 years with MIS-C had the highest rate of thrombosis at 19% (9/48). Notably, 71% of TE that were not present on admission occurred despite thromboprophylaxis. Multivariable analysis identified the following as significantly associated with thrombosis: age ≥12 years, cancer, presence of a central venous catheter, and MIS-C. In patients with COVID-19 or MIS-C, hospital mortality was 2.3% (13/564), but was 28% (5/18) in patients with thrombotic events. Our findings may help inform pediatric thromboprophylaxis strategies.


2021 ◽  
pp. 089719002110023
Author(s):  
Matt G. McKenzie ◽  
Yeunju (Michelle) Lee ◽  
Julin Mathew ◽  
Megan Anderson ◽  
Alison T. Vo ◽  
...  

Objective: To evaluate the use of tocilizumab in a community hospital setting for critically ill patients with severe COVID-19. Design: A retrospective case series Setting: Five community hospitals within 1 urban health system Patients: Adult patients whom received tocilizumab between March 27th, 2020 to April 30th, 2020 for severe COVID-19. Interventions: None. Measurements and Main Results Sixteen patients in total were evaluated from the 5 community hospitals. The mean (± SD) age of the patients was 53.9 ± 9.2 years, 56% were men, and the most common comorbidities present on admission were hypertension (31%) and diabetes mellitus (25%). All patients received at least 1 other treatment modality for COVID-19 (steroids, hydroxychloroquine, or convaslescent plasma). Additionally, all patients on admission to intensive care units had severe COVID-19 with 56% requiring mechanical ventilation with a pre-tocilizumab median (IQR) Pao2: Fio2 of 84 (69 – 108.6), 19% requiring vasopressor support, and inflammatory markers (CRP, LDH, ferritin, and IL-6) were elevated. The median (IQR) tocilizumab dose was 400 mg (400-600) which correlated with a weight-based mean (± SD) dose of 5.4 mg/kg ± 1.3. Of the 16 patients that received tocilizumab, 8 (50%) were discharged home, 7 (44%) died, and 1 (6%) was still hospitalized at the end of data collection. Patients who died were more likely to be older 62 ± 2 years, female (57%), had a higher rate of mechanical ventilation (86%) and vasopressors (43%) use at baseline, and had a higher median (IQR) IL-6 level prior to tocilizumab administration 550 pg/mL (IQR 83-1924). There were no reported adverse drug reactions reported after the administration of tocilizumab for any patient. Conclusions: Our findings do not support the effectiveness of tocilizumab in treatment of severe COVID-19 infection in critically ill patients.


2021 ◽  
Vol 19 ◽  
pp. 205873922110644
Author(s):  
Ruza Stevic ◽  
Nikola Colic ◽  
Branislava Milenkovic ◽  
Dragan Masulovic

Objectives The purpose of this study was to describe the severity of the radiographic findings of COVID-19 over time and to assess their correlation with the duration of symptoms prior to admission, CT scores, and disease severity. Methods A retrospective analysis of patients with COVID-19 confirmed by reverse transcription polymerase chain reaction (RT-PCR) and CXR who were admitted at the university hospital was performed between March 25 and 30 April 2020. Baseline and serial CXRs were reviewed, along with onset and disease time courses. Correlations between CXR scores and CT scores, durations of symptoms and disease severity were evaluated; and also between regression times and disease severity. Results Of 208 total patients, there were 33 mild (15.9%), 103 moderate (49.5%), and 72 severe-critical (34.6%) cases. The most frequent symptoms were fever, cough, fatigue, and dyspnea. Dyspnea was more frequent in patients with severe and critical disease ( p < 0.001). The duration of symptoms experienced prior to admission was longer in patients with severe and critical disease than in moderate cases ( p < 0.05). Abnormalities on CXR were present on admission in 83.2% patients, with reticulations being the most common finding. CXR scores correlated with duration of symptoms prior to admission and CT scores ( p < 0.05 and p < 0.001, respectively). The median radiographic score of the severe-critical-type group was significantly higher than the moderate type ( p <  0.001) and regression time correlated with disease severity ( p < 0.001). Conclusion Our study showed that despite the limitations, CXR remains a very important tool for diagnosing and managing patients with COVID-19.


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