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INTRODUCTION: SARS-CoV-2 (COVID-19) has continued to be a public health emergency, affecting almost 450 million people worldwide, with a disproportionate significant disease burden in the elderly community. Our objective is to provide population specific prognostic markers upon description of demographic factors, clinical characteristics, diagnostic variables, treatment characteristics and outcome variables in critically ill geriatric patients with acute hypoxic respiratory failure due to COVID-19 infection. METHOD(S): This is a retrospective chart review of 165 patients admitted to a single institution's medical and cardiovascular intensive care unit between the dates of March 01, 2020 and December 31, 2020. Inclusion criteria was patients age greater than or equal to 65 years, documented positive COVID-19 polymerase chain reaction test result and a diagnosis of acute hypoxic respiratory failure. Our primary end point evaluated the rate of mortality in relation to multiple variables during intensive care unit admission. RESULT(S): Of 165 patients, 45 patients were excluded. Of the remaining 120 patients, 41 were females and 79 were males. Four independent risk factors are significantly associated with higher odds of mortality for the concerned population: presence of solid tumor (AOR: 0.002, 95% CI: < 0.001, 0.31), maximum value of PaCO2 (AOR: 1.094, 95% CI: 1.029, 1.163), Charlson comorbidity index (AOR: 2.962, 95% CI: 1.59, 5.52), and use of diuretics (AOR: 0.015, 95% CI: < 0.001, 0.49). CONCLUSION(S): It was to our surprise that the mortality rate among those intubated was not statistically significant. However, it has been shown in prior research, which is in alignment with our results, that mechanical ventilation does not necessarily result in increased mortality. Certain factors were found to be poor prognostic markers during intensive care unit admission, which may predict a higher rate of mortality in those patient populations.
ABSTRACT
SESSION TITLE: Quality Improvement SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 pm - 2:30 pm PURPOSE: Age adjusted D-dimer is a well validated method by which to rule out pulmonary embolism in patients with low to intermediate pretest probability. The specificity of the traditional D-dimer cutoff (500 mcg/L) decreases with age and leads to false-positive results and unnecessary imaging tests. When an age-adjusted cutoff is used (age x 10 mcg/L), specificity improves, and excessive testing is avoided. METHODS: We began by collecting retrospective data for all patients who underwent D-dimer testing over the course of a 29-month period (from October 2017 through February 2020) within our 400 bed community hospital. We determined how many of these patients underwent further imaging with either a CT angiogram (CTA) or ventilation-perfusion (VQ) scan. We then implemented a messaging system within the hospital’s electronic medical record (EMR) with the purpose of reminding providers to consider age-adjusted D-dimer values prior to ordering imaging. Post-intervention data was collected over a period of six months (August 2021 – January 2022). Patients who tested COVID positive were excluded from analysis. RESULTS: A total of 1054 patients were included in the pre-intervention group, while 371 patients were included in the post-intervention group. There was no significant difference in age between the two groups (p = 0.241). A total of 13.6% (n = 143) of the patients in the pre-intervention group underwent CTA or VQ scan despite having a D-dimer below the age-adjusted cutoff, indicating that the patient did not require any imaging. Post-intervention, a total of 9.2% (n = 34) of patients underwent CTA or VQ scan despite having D-dimer values below the age-adjusted cutoff. Using a chi-square test for association, there was a statistically significant decrease in unnecessary testing (χ2(1) = 5.343, p = 0.021). CONCLUSIONS: Despite high quality evidence that suggests the use of age-adjusted D-dimer is safe and effective for ruling out pulmonary embolism, many imaging tests are ordered based upon standard cutoff values. Implementing a reminder message within our hospital’s EMR system produced a significant reduction in inappropriate imaging. This ultimately resulted in less radiation for patients, as well as an estimated cost savings of $33,758 over a six-month period. Although statistically significant improvement was seen, further interventions, such as automatically adjusting D-dimer cutoff values within the EMR, may further reduce unnecessary imaging and avoid pop-up message fatigue. CLINICAL IMPLICATIONS: Built-in EMR reminders to use age-adjusted D-dimer cutoff values may decrease unnecessary CTAs and VQ scans. This may translate into reduced patient irradiation and decreased overall healthcare costs without sacrificing patient care. DISCLOSURES: No relevant relationships by Naren Bhupatiraju No relevant relationships by Meagan Mayo No relevant relationships by Katherine Reano