ABSTRACT
RATIONALE The COVID-19 pandemic led to rapid changes in care-delivery for intensive care unit (ICU) patients, due to factors including high ICU strain, shifting team member roles, and changes in care locations. As these changes may have not only impacted patients with COVID-19 but also critically ill patients without COVID-19, we assessed changes in common ICU practices for mechanically ventilated patients without COVID before and after the start of the COVID-19 pandemic. METHODS We used the Premier Healthcare Database to identify mechanical ventilated ICU patients in the US from January 1, 2016 - December 31, 2020. Patients were excluded if they had an ICD-10 diagnosis of COVID-19 (U07.1) or if they were admitted to a hospital that did not contribute data for all five years. We assessed annual rates of common ICU imaging studies (chest CT scan, chest x-ray, lower extremity doppler ultrasound), bedside diagnostics (electrocardiogram, electroencephalogram), and bedside procedures (arterial line, central venous catheterization, bronchoscopy) and annual mortality rates. We used interrupted time series analysis, adjusted for seasonality and autocorrelation where present, to evaluate trends in ICU practices prior to the pandemic (March 2016 - February 2020), at the onset of the pandemic (April 2020) and as the pandemic progressed (April 2020 - December 2020). March 2020, as the US transitioned into the pandemic, was excluded from the analysis. RESULTS We identified 584,393 mechanically ventilated patients without COVID- 19 at 509 hospitals. Trends in ICU procedures and mortality are illustrated in Figure 1. At the onset of the pandemic, use of chest x-ray (-35.6% [-53.5 to -17.8%, p<0.001]), electrocardiogram (-14.8% [-21.9 to -7.6%, p<0.001]), and bronchoscopy (-1.2% [-1.8 to -0.6%, p<0.001]) decreased;rates of lower extremity doppler (-1.8% [-4.1 to -0.5%, p=0.12]), electroencephalogram (-0.8% [- 1.7 to 0.1%, p=0.09]), arterial lines (-0.09 [-1.0 to 0.9%, p=0.85]) and central venous catheters (+0.2 [-1.3 to 1.7%, p=0.77]) did not significantly change;use of chest CT increased 2.6% (0.9 to 4.3%, p=0.001). With the exception of chest CT, arterial lines, and central venous catheters, trends in all other measured procedures increased as the pandemic progressed, compared with pre-pandemic trends. There was no significant trend change in mortality at the onset of the pandemic or during the pandemic. CONCLUSIONS Multiple practice patterns changed among patients without COVID-19 early during the pandemic. However, no change in mortality was seen during this time. These findings warrant further investigation to determine their impact on patientcentered outcomes.
ABSTRACT
Rationale. Prone positioning (PP) of patients with moderate-severe acute respiratory distress syndrome (ARDS) is an evidence-based and guideline-recommended practice, but our 2019 survey found that fewer than half of Massachusetts ICUs could routinely offer PP. As studies have described rapid adoption of evidence- and nonevidence- based practices alike during COVID-19, we re-surveyed Massachusetts ICUs in 2021 to determine if institutional-level adoption of PP among intubated patients had changed during the COVID-19 pandemic;we additionally ascertained adoption of awake PP. Methods. In follow-up to our 2019 survey, we surveyed intensive care units (ICUs) at all acute-care hospitals in Massachusetts, June-October 2021. The survey asked: “Does your ICU have the ability to prone intubated patients?” (“Yes, routinely,” “Case-by-case,” or “No”). Follow-up questions inquired if ICUs had protocols/guidelines on intubated PP, trained nurses in intubated PP, and whether awake PP had been adopted. We collected descriptive hospital data (number of ICU and hospital beds, nonprofit status, teaching status, case-mix index) and tested for associations with chi-square tests. Results. Of the 57 acute care hospitals in Massachusetts with ICUs, 47 responded to the survey (82% response;compared to 54/60 [90%] in 2019;three hospitals surveyed in 2019 had closed ICUs in 2021). The number of hospitals able to routinely perform PP in intubated patients increased from 24 (44%) to 39 (83%);hospitals able to perform PP among intubated patients on a case-by-case basis or not at all decreased from 15 (28%) to 5 (11%) and 15 (28%) to 3 (6%), respectively (p<0.001) (Figure 1). ICUs with a protocol/guideline for intubated PP increased from 27 (50%) to 43 (92%) (p< 0.001);ICUs that had trained some or all nurses in intubated PP increased from 34 (63%) to 45 (96%) (p<0.001). In contrast to 2019, in 2021 there were no associations between availability of intubated PP and hospital/ICU bed number, teaching status, nonprofit status, or case-mix index. In 2021, 43 (92%) of Massachusetts ICUs had adopted awake PP, 19 of whom had not adopted routine PP of intubated patients in 2019, and 4 of whom had not adopted intubated PP in 2021. Conclusions. There was a significant increase in the proportion of Massachusetts ICUs that had adopted evidence-based, guideline-recommended PP in intubated patients by 2021. At the same time, almost all ICUs also adopted non-evidence-based PP in awake patients. Our results illustrate that factors other than available evidence play a large role in practice adoption.