Transitions of Care and Readmissions in Patients with Diabetes Receiving CGM at Hospital Discharge

Background: Use of inpatient continuous glucose monitoring (CGM) has increased during the COVID-19 pandemic. The objective of this study was to evaluate outpatient follow-up patterns and readmission rates for patients discharged from the hospital with CGM. Research Design and Methods: We retrospectively identified patients with diabetes (DM) aged >18 years who were admitted between 3/27/20 and 5/13/21 and received Freestyle Libre or Freestyle Libre 2 14-day sensor at the time of discharge from the hospital. The sensor was placed in the hospital by our diabetic educator. Only the first admission was included. The medical record was reviewed to determine attendance at outpatient follow-up visit, CGM downloading and prescribing at that visit, and readmission within 30 days. Results: 87 patient charts were analyzed (31% type 1 DM, 66% type 2 DM, 3% other). The most common reasons for CGM placement were patients new to insulin (40%), DKA (34%), new diabetes diagnosis (30%), or HHS (5%). Follow-up information was not available for 25 patients (29%). The remaining 62 patients had scheduled follow-up within our system. 42 of those patients (68%) attended their follow-up appointment while 14 patients (33%) attended follow-up in an endocrine clinic. Among the 42 patients who attended follow-up, 8 patients (19%) had CGM data downloaded and 18 patients (43%) were prescribed CGM.Of the patients who attended endocrine follow-up, 50% had CGM downloads, compared to only 4% of patients seen in non-endocrine clinics (p = 0.001). Similarly, 79% of patients with endocrine follow-up were prescribed CGM sensors, while 25% of patients seen in non-endocrine clinics received a CGM prescription (p = 0.001). For patients newly diagnosed with DM and available follow-up data, 89% (N=16) attended their appointment. Overall, 16% of patients were readmitted within 30 days. Of the patients readmitted, only 17% attended outpatient follow-up and none had CGM downloaded or prescribed.Backward binary logistic regression was used to assess the relationship between outcomes (follow-up attendance and readmission) and variables (including diagnosis and follow-up location) in the 62 patients with follow-up data. In the final models, a new diagnosis of DM was associated with follow-up attendance, and type 1 DM and follow-up nonattendance were associated with 30-day readmission. Results were verified using exact logistic regression. Conclusions: Downloading and prescribing of CGM after hospital discharge occurred in less than half of patients, but occurred more frequently in endocrine clinics. A specialized transition of care clinic may benefit patients discharged with CGM. Follow-up attendance among readmitted patients was poor. Patients with a new diagnosis of DM had good follow-up attendance and may be good candidates for CGM at hospital discharge, which can be examined in future prospective studies.Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

The Impact of Morbid Obesity on Patients with COVID-19 who Develop Respiratory Failure requiring Extracorporeal Membrane Oxygenation

Background: In patients with COVID-19 and respiratory failure, class 3 obesity (body mass index > 40 kg/m2) has been associated with worse survival. Obese patients on mechanical ventilation with progressively more severe acute respiratory syndrome (ARDS) may be offered venovenous (VV) extracorporeal membrane oxygenation (ECMO) therapy. The impact of morbid obesity on the outcome of COVID-19 patients supported with VV ECMO has been underexplored. Methods: This is a multicenter, retrospective observational cohort analysis of critically ill adults with COVID-19 ARDS requiring advanced mechanical ventilation with or without VV ECMO. Data was collected from 236 international institutions forming the COVID-19 Critical Care Consortium international registry. Patients were admitted between January 2020 to December 2021. Included patients were stratified by ECMO status and a BMI threshold at 40 kg/m2. Median values with interquartile range (IQR) were used to summarize continuous variables and multi-state analysis was used to explore the effect of Class 3 obesity on the study endpoints of patient survival to discharge or death. Results: Complete data was available on 8851 of 9059 patients on mechanical ventilation, of which 767 patients required VV ECMO. For the entire study group, older age and male gender were associated with an increased risk of death. The demographics and comorbidities of the higher BMI (H >40 kg/m2) and lower BMI (L ≤40 kg/m2) cohorts were similar with the exception of age and weight. Patients with a higher BMI were younger. The median age of the H, non-ECMO cohort was 56 years (46-64), and the H, ECMO cohort was 41 years (35-51) versus the L, non-ECMO cohort of 64 years(55-71), and the L, ECMO cohort of 53years (45-60). Patients requiring VV ECMO had higher SOFA scores, experienced longer ICU and hospital lengths of stay, and a longer duration of total mechanical ventilation. Table The median time to intubation was longer in the mechanical ventilation only group (2 versus 0 days). Predictors for requiring ECMO included younger age, higher BMI and male gender. Risk factors for death included advancing age (every 10 years), male gender and increasing BMI (every 5kg/m2). The association between BMI and a higher rate of death was reduced in the mechanical ventilation only group (HR 0.92, 95% confidence interval 0.85 to 0.99). Conclusion: In patients with severe ARDS due to COVID-19 requiring mechanical ventilation, the likelihood of progressing to VV ECMO therapy or experiencing death is impacted by age, gender and higher BMI. The cohort of COVID-19 patients that ultimately required ECMO appear to be sicker at time hospital admission owing to the shorter time until mechanical ventilation. It appears the association between increasing BMI and death differs among the ECMO and mechanical ventilation alone cohorts. We would advocate for a prospective study to determine the benefit of VVECMO for the obese patient requiring VV-ECMO for COVID-19 ARDS. (Figure Presented).

A new frontier: Navigating hospital pharmacy practice during the covid-19 pandemic

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first manifested in Wuhan, China in December 2019 as multiple cases of pneumonia with unknown etiology. This was the herald of an infectious catastrophe that would eventually affect millions of people across the world, claim countless lives, and uproot the very foundations of modern-day healthcare practice. Hospital pharmacists, alongside with physicians, nurses, and numerous other disciplines, are an integral part of the healthcare team that responded to this pandemic. The purpose of this article is to highlight the teamwork, determination, and innovativeness demonstrated by clinical pharmacists at a 510-bed community hospital in response to the coronavirus disease of 2019 (COVID-19). Pharmacists rose to the occasion to ensure that patients continue to receive the best therapy possible during this pandemic, and they supported other disciplines to ensure a collaborative response. Despite the unprecedented challenges posed to hospital pharmacy practice in the setting of COVID-19, our pharmacy team’s response has resoundingly proven the resiliency of the human spirit, and shows that nothing is insurmountable in the face of collaboration, creativity, and an overwhelming desire to care for our community. © 2021 Marmara University Press.

Neuromuscular blocking agents in critically-ill COVID-19 patients requiring mechanical ventilation

RATIONALE. Neuromuscular blocking agents (NMBA) are used in patients with moderate to severe acute respiratory distress syndrome. NMBA have also been used in COVID-19 patients who required mechanical ventilation (MV), but their benefit-to-risk ratio remains uncertain.METHODS. We investigated the effects associated with the use of NMBA in COVID-19 patients who required MV from January 1, 2020 to October 31, 2020 in 153 hospitals across 6 continents, comprising the COVID-19 Critical Care Consortium. Cox proportional hazards analysis was conducted to study the impact of NMBA on 28-day intensive care unit (ICU) mortality. Hospital/ICU lengths of stay were appraised. We performed a propensity score (PS) matching analysis to control confounding factors.RESULTS. 1227 patients were eligible for analysis, among those 598 (48.7%) received NMBA for 2 days or longer, with a median time from ICU admission to commencement of NMBA therapy of 0 day (IQR 0-1 days). The median duration of NMBA therapy was 2 days (N=789, IQR 1-5). In comparison with standard of care, treatment with NMBA was more frequent in obese (31% vs. 39%, P = 0.03) and diabetic patients (2% vs. 8%, P <0.01) and less frequent in patients with hypertension (52% vs. 46%, P =0.04) or cardiac diseases (21% vs. 14%, P =0.003). Upon commencement of MV, patients who underwent NMBA therapy vs those who did not presented a PaO2/FiO2 of 136.1±69.2 vs. 162.7 ±125.8 (p<0.01), required more often ECMO (10% vs 5.2%, p <0.01) and prone position (25.1% vs 6.2%, p <0.01). Unadjusted 28-day all-cause mortality was similar (58.2% vs. 62.4%, P =0.134) between patients without or with NMBA therapy, respectively, but length of MV (3 days [2-5] vs. 6 [3-12] P <0.01) and ICU stay (8 days [4-14] vs. 13 [7-19] P <0.01) were prolonged. After PS matching, NMBA therapy was strongly associated with 28-day ICU mortality (adjusted HR 3.18, 95% CI 2.65-3.81, P <0.01). CONCLUSION. Use of NMBA in COVID-19 patients requiring MV is associated with increased 28-day mortality, delayed discontinuation of MV and prolonged ICU stay.

Factors associated with mortality in patients with COVID-19 requiring mechanical ventilation: An international cohort study from 139 intensive care unit across 6 continents

Rationale: Patients with COVID-19 commonly develop severe hypoxemic respiratory failure and require invasive mechanical ventilation (MV). The disease burden and predictors of mortality in this population remain uncertain. Methods: Prospective observational cohort study from 139 intensive care units of the international COVID-19 Critical Care Consortium. Patients enrolled from January 14th through November 31st 2020 were included in the analysis. Patient's characteristics and clinical data were assessed. Multivariable Cox proportional hazards analysis was conducted to identify indipendent predictors of mortality within 28 days from commencement of MV. Results: 1578 patients on MV were included into the analysis. Mean±SD age was 59 years±13 and patients were predominantly males (66%). 542 Patients (34.4%) died within 28 days from commencement of MV. Nonsurvivors were slightly older (mean age±SD 62±13 vs. 59±13) and presented more frequently hypertension, chronic cardiac disease and diabetes. Median (IQR) PaO2/FiO2 upon commencement of MV was 96 (68-135) and 111 (81-173) in patients who did not survive vs. survivors, respectively (p=0.04). ECMO (13% vs 25%, p<0.01), inhaled nitric oxide (11% vs 15%, p=0.02) and recruitment manoeauvres (26% vs 31%, p<0.01) were used less frequently in patients who did not survive. Independent risk factors associated with 28-day mortality included age older than 70 years (hazard ratio [HR], 2.83;95% CI, 1.32-6.07), higher creatinine levels upon ICU admission (HR, 1.20;95% CI, 1.03-1.40), and lower pH within 24h from commencement of MV (HR, 0.12;95% CI, 0.02-0.62), while a shorter period (day) from early symptoms to hospitalisation reduced mortality risks (HR, 0.96;95% CI, 0.93-0.99). Conclusions: Our findings from a large international cohort of critically-ill COVID-19 patients on mechanical ventilation emphasises that elderly patients, not promptly admitted to the hospital, and who present higher creatinine levels and acidosis are at higher risk of mortality.

Prone position during veno-venous extracorporeal membrane oxygenation for COVID-19

Objective: Prone positioning for severe acute respiratory distress syndrome (ARDS) is associated with improved outcome. It is unclear whether prone positioning during Venovenous extracorporeal membrane oxygenation (VV ECMO) has survival benefit. The study investigated the impact of prone positioning on survival during VV ECMO support for COVID-19 acute respiratory failure. Methods: An observational analysis of VV ECMO patients using the COVID-19 Critical Care Consortium (COVID Critical) international registry. We used a multi-state survival model to compare the outcomes of patients treated with or without prone positioning during ECMO. Results: There were 213 COVID-19 patients at 67 participating institutions who were supported with VV ECMO from February 19, 2020, to October 31, 2020. Proning was used in 160 patients (75%) before initiation of ECMO and in 67 patients (31%) during ECMO. Prone positioning during ECMO support was associated with reduced mortality (hazard ratio 0.33, 95% CI, 0.15 to 0.73). Conclusions: Our study highlights that prone-positioning during VV ECMO support for refractory COVID- 19-related ARDS is associated with reduced mortality. Given our observational study design, a randomized controlled trial of prone positioning on VV ECMO is needed to confirm these findings.