Frequent tracheal suctioning is associated with extubation failure in patients with successful spontaneous breathing trial: a single-center retrospective cohort study

Background Extubation failure, i.e., reintubation in ventilated patients, is a well-known risk factor for mortality and prolonged stay in the intensive care unit (ICU). Although sputum volume is a risk factor, the frequency of tracheal suctioning has not been validated as a predictor of reintubation. We conducted this study to examine whether frequent tracheal suctioning is a risk factor for reintubation. Patients and methods We included adult patients who were intubated for > 72 h in the ICU and extubated after completion of spontaneous breathing trial (SBT). We compared the characteristics and weaning-related variables, including the frequency of tracheal suctioning between patients who required reintubation within 24 h after extubation and those who did not, and examined the factors responsible for reintubation. Results Of the 400 patients enrolled, reintubation was required in 51 (12.8%). The most common cause of reintubation was difficulty in sputum excretion (66.7%). There were significant differences in sex, proportion of patients with chronic kidney disease, pneumonia, ICU admission type, the length of mechanical ventilation, and ICU stay between patients requiring reintubation and those who did not. Multivariate analysis showed frequent tracheal suction (> once every 2 h) and the length of mechanical ventilation were independent factors for predicting reintubation. Conclusion We should examine the frequency of tracheal suctioning > once every 2 h in addition to the length of mechanical ventilation before deciding to extubate after completion of SBT in patients intubated for > 72 h in the ICU.

Blood Transfusion Trends in the United States, National Inpatient Sample, 2015-2018

Blood transfusions are among the most common therapeutic procedures performed in hospitalized patients. This study evaluates contemporary national trends in RBC, plasma, platelet and cryoprecipitate transfusions. National Inpatient Sample (NIS), the largest all-payer inpatient database representing 94-97% of US population, was evaluated from the 4th quarter of 2015 through 2018. Quarterly trends for the percentage of hospitalizations with a transfusion procedure were separately examined for each blood product using log binomial regression and reported as quarterly percent change (QPC). The percentage of hospitalizations with a RBC transfusion decreased from 4.22% (2015Q4) to 3.79% (2018Q4) (QPC=-0.72[95%CI=-1.26, -0.19]; Ptrend=0.008). While plasma transfusions also decreased QPC=-1.33(95%CI=-2.00, 0.65;Ptrend<0.001), platelet transfusions remained stable QPC=-0.13[95%CI=-0.99,0.73]; Ptrend=0.766). In contrast, hospitalizations with cryoprecipitate utilization significantly increased QPC=2.01(95%CI=0.57,3.44; Ptrend=0.006). Significant quarterly reductions in RBC transfusions were also seen among many -but not all- strata of sex, race/ethnicity, patient risk-severity, and admission type (elective versus non-elective). Despite significant declines in RBC transfusions among older adults, there were no significant changes among pediatric age-group (<18-years) and those 18-49 years. The decline in RBC and plasma transfusions suggests steady incorporation of robust evidence base showing safety of restrictive transfusions. Increased cryoprecipitate use may be reflective of wider adoption of hypofibrinogenemia management and hemostasis testing for coagulopathic patients.

The 30-days hospital readmission risk in diabetic patients: predictive modeling with machine learning classifiers

Background and objectives Diabetes mellitus is a major chronic disease that results in readmissions due to poor disease control. Here we established and compared machine learning (ML)-based readmission prediction methods to predict readmission risks of diabetic patients. Methods The dataset analyzed in this study was acquired from the Health Facts Database, which includes over 100,000 records of diabetic patients from 1999 to 2008. The basic data distribution characteristics of this dataset were summarized and then analyzed. In this study, 30-days readmission was defined as a readmission period of less than 30 days. After data preprocessing and normalization, multiple risk factors in the dataset were examined for classifier training to predict the probability of readmission using ML models. Different ML classifiers such as random forest, Naive Bayes, and decision tree ensemble were adopted to improve the clinical efficiency of the classification. In this study, the Konstanz Information Miner platform was used to preprocess and model the data, and the performances of the different classifiers were compared. Results A total of 100,244 records were included in the model construction after the data preprocessing and normalization. A total of 23 attributes, including race, sex, age, admission type, admission location, length of stay, and drug use, were finally identified as modeling risk factors. Comparison of the performance indexes of the three algorithms revealed that the RF model had the best performance with a higher area under receiver operating characteristic curve (AUC) than the other two algorithms, suggesting that its use is more suitable for making readmission predictions. Conclusion The factors influencing 30-days readmission predictions in diabetic patients, including number of inpatient admissions, age, diagnosis, number of emergencies, and sex, would help healthcare providers to identify patients who are at high risk of short-term readmission and reduce the probability of 30-days readmission. The RF algorithm with the highest AUC is more suitable for making 30-days readmission predictions and deserves further validation in clinical trials.

Increase of Antimicrobial Consumption in a Tertiary Care Hospital during the First Phase of the COVID-19 Pandemic

Background: The COVID-19 pandemic poses novel challenges in antimicrobial consumption metrics and stewardship strategies. COVID-19 patients became the major cause of hospital admission during the first wave of the pandemic, often leading to an antimicrobial prescription upon admission or treatment for superinfections. The aim of this study was to understand how antimicrobial consumption was impacted at the beginning of the pandemic in a tertiary care hospital, a reference center for COVID-19. Materials and Methods: A retrospective before-and-after study was done. Descriptive statistics of discharges, patient-days, and antimicrobial use indicators (defined daily doses (DDD)/100 discharges, DDD/100 patient-days) for various groups were calculated for the first three months of the pandemic (March, April, and May 2020) as a quarterly value, and for each year in 2011–2019, and their annual percentage changes were used to estimate 95% confidence intervals. The indicators were compared to patient type (medical/surgical), type of admission (urgent/elective), and age groups using Spearman’s correlation coefficient. Results: Statistically significant increases occurred in 2020 for total antibacterials, macrolides, cephalosporins, amoxicillin/clavulanic acid, carbapenems, meropenem, and third-generation cephalosporins, while a reduction was seen in cefazolin/cefoxitin. A correlation was found between antibacterial consumption and patient or admission type. In 2020, unlike in pre-pandemic years, there was a different impact in DDD/100 discharges and DDD/100 patient-days due to increased lengths-of-stay and longer antimicrobial therapy. Conclusions: The COVID-19 pandemic led to an increase in antimicrobial consumption with a different impact in DDD/100 discharges and DDD/100 patient-days. This highlights the need to use both indicators simultaneously to better understand the causes of antimicrobial consumption variation and improve the design of effective antimicrobial stewardship interventions.

Soluble neprilysin and survival in critically ill patients

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): -) Association for the Promotion of Research on Arteriosclerosis, Thrombosis and Vascular Biology (ATVB) -) Ludwig Boltzmann Cluster for Cardiovascular Research BACKGROUND Critically ill patients admitted to an intensive care unit (ICU) exhibit a high mortality rate irrespective of the initial cause of hospitalization. Neprilysin is a neutral endopeptidase degrading an array of vasoactive peptides, including bradykinin, adrenomedullin and natriuretic peptides and became a drug target within the treatment of heart failure with reduced ejection fraction. The aim of this study was to analyze whether circulating levels of neprilysin at ICU admission are associated with 30-day mortality, due to its physiologic effects. METHODS In this single-center prospective observational study, 222 consecutive patients admitted to a tertiary ICU at a university hospital were included. Blood was drawn at admission and soluble neprilysin levels were measured using ELISA. RESULTS Median simplified acute physiology score was 44 and 30-day mortality was 35.1% in medical patients (n = 151) and 7.1% in patients after surgery and heart valve interventions (n = 71). Neprilysin levels did not differ according to survival status after 30 days and admission type. When assessing neprilysin and survival according to admission type, no association was found in medical patients, while in patients after surgery or heart valve intervention, 30-day survivors exhibited significantly lower neprilysin levels as compared to those that died within 30 days (660.2, IQR: 156.4 – 2512.5 pg/ml versus 6532.6, IQR: 1840.1 – 10000.0 pg/ml; p = 0.02). Neprilysin predicted mortality independently from age, gender, NT-proBNP, and SAPS II score (OR per 1-SD increase of neprilysin: 2.52, 95%CI 1.01–6.32; p = 0.049). Additionally, neprilysin was markedly elevated in patients with sepsis and septic shock (p < 0.05). CONCLUSION At the time of ICU-admission, circulating levels of neprilysin independently predicted 30-day mortality in patients following cardiac surgery or heart valve intervention, but not in critically ill medical patients.

Experiences from a non-COVID hub referral orthopedic trauma hospital during the COVID-19 pandemic in Turkey

<p><strong>Background:</strong> During the COVID-19 pandemic period, resources should be reorganized to treat the increased burden of COVID-positive patients under the best conditions while simultaneously providing non-deferrable treatment to patients with no suspicion of COVID-19. In this study, we aimed to analyse the trauma patient profile and treatment strategies that emerged in the regional orthopaedic and traumatology hospital during the pandemic period after the implementation of “hub and spoke” organization among the orthopaedic and traumatology clinics.</p><p><strong>Methods:</strong> This cross-observational study was conducted in a training and research hospital in the field of orthopaedics and traumatology that was converted to a non-COVID referral orthopaedic trauma center during the pandemic. Gender, age, length of hospitalization, duration of trauma, place of trauma, severity of trauma, type of admission, type of anaesthesia and site of trauma were evaluated in the patients that presented between March 16 and May 16, 2020.</p><p><strong>Results:</strong> Of the orthopaedic trauma patients requiring surgery, 169 (62.6%) were men and 101 (37.4%) were women. In comparison of the data with that of the last year, significant increases were observed in the number of home traumas (241.5%), low-energy traumas (87.4%), patients referred from other institutions (328.9%), regional anaesthesia patients (124.2%) and patients with hip traumas (226.7%). The length of hospitalization decreased significantly (p&lt;0.05).</p><p><strong>Conclusions:</strong> The creation of hub and spoke organization through the cooperation of orthopaedics and traumatology clinics in the region can reduce the burden on pandemic hospitals by isolating trauma patients requiring orthopaedic surgery who were not suspected of COVID-19 and directing them to dedicated orthopaedics and traumatology hospital.</p>

Economic incentives and survival probabilities for chronic and multimorbidity patients - Do the relationships depend on patient pathways?

Background: The Norwegian Coordination Reform (CR) in 2012 introduced new economic incentives aimed at weaknesses in interaction between primary care, social care and specialist care. This paper studies the association of a new co-payment scheme on the 30-day and 90-day survival probabilities for chronic and multimorbidity patients. We also analyse whether admission types ⸺planned or emergency⸺ matters for survival rates, and the importance of patient pathways. Several different pathways are possible, depending on where patients came from before being admitted to hospital and their destination after discharge from hospital. Methods: The study uses data from three different registers for the period 2010 to 2013. We consider 30 common chronic conditions for which administrative data are available (n=563,096 in-patient episodes). We look at three mutually exclusive pathways. They are relevant and important in terms of the number of patients depending on co-operation and co-ordination between health care providers. Using a quasi-experimental design—the difference-in-differences approach—we estimate the associations between the co-payment scheme and survival probability by admission type and by patient pathway.Results: Overall, the changes in survival probabilities are found positively and significantly associated with the co-payment scheme. For emergency admissions such a significant positive association is observed for the 30-day survival only, whereas, for planned admissions a significant positive relationship is evident for the 90-day survival only. Pathway-specific results indicate positive and significant associations with survival probabilities (both the 30-and 90-day) for all admissions and emergency admissions for two specific pathways. Multimorbidity subgroup analysis generally shows no significant relationship with survival probabilities, but pathway-specific analyses show significant positive associations between emergency admissions and the 90-day survival for patients following two specific pathways. However, for planned admissions we find a significant negative association with the 30-day survival for multimorbidity patients following one specific pathway.Conclusion: We conclude that the survival probabilities are positively associated with the new economic incentives but the result depends on admission type, patient pathway and multimorbidity status. Without modelling admission type, pathway and multimorbidity explicitly, one may overlook important relationships associated with the economic incentives. Future policy evaluations in any pertinent context should envisage these aspects.

Measuring the Audience Experience at the Jazzaldia Festival, San Sebastian, Spain

Audience research in the cultural sector has been increasingly gaining the attention of researchers and practitioners. This paper explores audience experience as an interactive co-created process between audiences and the program offer in the jazz festival context. As a result of this interaction, each such experience is unique,and the perceived value differs from one to the other. Inspired by previous research on audience experience in the field of theatre performances and musicals, we applied the Art Audience Experience Index to the context of jazz festivals, in this case,a well-established and successful Basque festival: Jazzaldia Festival, San Sebastián (Spain). The Index measures four indicators: Knowledge, Risk, Authenticity and Collective Engagement. These were utilized to identify co-creation links between festival setting features (paid versus free admission and indoor versus outdoor venue) and audience profiles (education level and music background). The results are obtained from 406 valid questionnaires and reveal the importance audiences give to their live music experience in general, and their satisfaction with jazz concerts in relation to festival concerts’ admission, type of venue, participants’ educational level and music background. This study contributes to the body of knowledge on audience experience in jazz festivals by employing a tested methodological tool that has not been previously applied in the concert or festival setting. Furthermore, our work may help cultural managers acquaint themselves with their audiences to a greater extent, and incite reflection on interventions that might enhance the experience of their audiences.

Economic incentives and survival probabilities for chronic and multimorbidity patients - Do the relationships depend on patient pathways?

Background: The Norwegian Coordination Reform (CR) in 2012 introduced new economic incentives aimed at weaknesses in interaction between primary care, social care and specialist care. This paper studies the association of a new co-payment scheme on the 30-day and 90-day survival probabilities for chronic and multimorbidity patients. We also analyse whether admission types ⸺planned or emergency⸺ matters for survival rates, and the importance of patient pathways. Several different pathways are possible, depending on where patients came from before being admitted to hospital and their destination after discharge from hospital.Methods: The study uses data from three different registers for the period 2010 to 2013. We consider 30 common chronic conditions for which administrative data are available (n=563,096 in-patient episodes). We look at three mutually exclusive pathways. They are relevant and important in terms of the number of patients depending on co-operation and co-ordination between health care providers. Using a quasi-experimental design—the difference-in-differences approach—we estimate the associations between the co-payment scheme and survival probability by admission type and by patient pathway.Results: Overall, the changes in survival probabilities are found positively and significantly associated with the co-payment scheme. For emergency admissions such a significant positive association is observed for the 30-day survival only, whereas, for planned admissions a significant positive relationship is evident for the 90-day survival only. Pathway-specific results indicate positive and significant associations with survival probabilities (both the 30-and 90-day) for all admissions and emergency admissions for two specific pathways. Multimorbidity subgroup analysis generally shows no significant relationship with survival probabilities, but pathway-specific analyses show significant positive associations between emergency admissions and the 90-day survival for patients following two specific pathways. However, for planned admissions we find a significant negative association with the 30-day survival for multimorbidity patients following one specific pathway.Conclusion: We conclude that the survival probabilities are positively associated with the new economic incentives but the result depends on admission type, patient pathway and multimorbidity status. Without modelling admission type, pathway and multimorbidity explicitly, one may overlook important relationships associated with the economic incentives. Future policy evaluations in any pertinent context should envisage these aspects.