Development and Validation of a Renal Replacement after Trauma Scoring Tool.

BACKGROUND: Stress on the healthcare system requires careful allocation of resources such as renal replacement therapy (RRT). The COVID-19 pandemic generated difficulty securing access to RRT for trauma patients. We sought to develop a renal replacement after trauma (RAT) scoring tool to help identify trauma patients who may require RRT during their hospitalization. STUDY DESIGN: The 2017 to 2020 TQIP database was divided into a derivation (2017 to 2018 data) and validation (2019 to 2020 data) set. A 3-step methodology was used. Adult trauma patients admitted from the emergency department to the operating room or ICU were included. Patients with chronic kidney disease, transfers from another hospital, and emergency department death were excluded. Multiple logistic regression models were created to determine the risk for RRT in trauma patients. The weighted average and relative impact of each independent predictor was used to derive a RAT score, which was validated using area under receiver operating characteristic curve (AUROC). RESULTS: From 398,873 patients in the derivation and 409,037 patients in the validation set, 11 independent predictors of RRT were included in the RAT score derived with scores ranging from 0 to 11. The AUROC for the derivation set was 0.85. The rate of RRT increased to 1.1%, 3.3%, and 20% at scores of 6, 8, and 10, respectively. The validation set AUROC was 0.83. CONCLUSIONS: RAT is a novel and validated scoring tool to help predict the need for RRT in trauma patients. With future improvements including baseline renal function and other variables, the RAT tool may help prepare for the allocation of RRT machines/staff during times of limited resources.

Dawn of a New Normal: Resident and Faculty Attitudes in Adopting Virtual Conferences and Education.

BACKGROUND: The COVID-19 pandemic has dramatically changed education in medical residencies with the need to transition to a virtual format. The objective of this study is to assess the adoption of a virtual format for grand rounds, M&M, and education of the surgical department. METHOD: A 25 question online survey was developed using Qualtrics and distributed to faculty and resident physicians in the Department of Surgery from March to April 2021. RESULTS: Fifty four out of 79 potential respondents (68%) completed the survey. Twenty-seven out of 54 (50%) respondents stated they were more likely to be participating in another activity most of the time or always. During to in-person conferences, 20/54 (37%) of participants reported being more distracted by other activities. Forty-two out of 54 (78%) participants strongly agree that virtual conferences are more flexible with their schedule and saves them travel time. All of the faculty want conferences to continue virtually (with or without an in-person component) citing virtual conferences are more flexible with their schedule and saves travel time. However, 4/26 (15%) of residents responded not wanting to continue virtual education citing work distractions and not truly having protected time. CONCLUSION: As the Coronavirus 2019 (COVID-19) pandemic is continuing with new variants, the virtual education and conference format is necessary. There is overwhelming support from both residents and faculty in favor of the virtual conference format due to flexibility, ease, and convenience. However, care must be taken to make sure that resident education time is truly protected.

Outcomes of COVID-19 adults managed in an outpatient versus hospital setting.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic continues to spread globally and as of February 4, 2021, there are more than 26 million confirmed cases and more than 440,000 deaths in the United States (US). A top priority of the Centers for Disease Control and Prevention (CDC) is to identify risk factors for severe COVID-19 illness. The objective of this study was to analyze the characteristics and outcomes of COVID-19 adults who were managed in an outpatient setting compared to patients who required hospitalization at US academic centers. METHODS: Using the Vizient clinical database, Discharge records of adults with a diagnosis of COVID-19 between March 1, 2020 and January 31, 2021 were reviewed. Outcome measures included demographics, characteristics, rate of hospitalization, and mortality, and data were analyzed based on inpatient versus outpatient management. RESULTS: Among COVID-19 adults, 1,360,078 patients were managed in an outpatient setting while 545,635 patients required hospitalization. Compared to hospitalized COVID-19 adults, COVID-19 adults who were managed in an outpatient setting were more likely to be female (56.1% vs 47.5%, p <0.001), white (57.7% vs 54.8%, p <0.001), within younger age group of 18-50 years (p<0.001) and have lower rate of comorbidities. Mortality was significantly lower in outpatient group compared to hospitalized group (0.2% vs 12.2%, respectively, p <0.01%). For outpatient group, mortality increased with increasing age group: 0.02% (52 of 295,112) for patients 18-30 years and 1.2% (1,373 of 117,866) for patients >75 years. The rate of hospitalization was lowest for age group 18-30 years at 10.6% (35,607 of 330,719) and highest for age group >75 years at 56.1% (150,381 of 268,247). CONCLUSION: This analysis of US academic centers showed that 28.6% of COVID-19 adults who sought care at one of the hospitals reporting data to the Vizient clinical database required in-patient treatment. The rate of hospitalization in our study was lowest for the youngest age group of 18-30 years and highest for age group >75 years. Beside older age, other factors associated with outpatient management included female gender, white race, and having commercial insurance.

Outcomes of obese patients hospitalized with COVID-19: the impact of prior bariatric surgery.

BACKGROUND: Obesity and several obesity-related co-morbidities are risk factors for severe COVID-19 disease. Because bariatric surgery successfully treats obesity-related conditions, we hypothesized that prior bariatric surgery may be associated with less severe COVID-19 disease. OBJECTIVES: To examine the association between prior bariatric surgery and outcomes in patients with obesity admitted with COVID-19. SETTING: United States METHODS: The Vizient database was used to obtain demographic and outcomes data for adults with obesity admitted with COVID-19 from May 2020 to January 2021. Patients were divided into 2 groups: those with and those without prior bariatric surgery. The primary outcome was in-hospital mortality. Secondary outcomes were mortality by age, sex, race/ethnicity, and co-morbidity; intubation rate; hemodialysis rate; and length of stay. Because the database only provides aggregate data and not patient-level data, multivariate analysis could not be performed. RESULTS: Among the 124,699 patients with obesity admitted with COVID-19, 2,607 had previous bariatric surgery and 122,092 did not. The proportion of patients ≥65 years of age was higher in the non-bariatric surgery group (36.0% versus 27.6%, P < .0001). Compared with patients without prior bariatric surgery, patients with prior bariatric surgery had lower in-hospital mortality (7.8 versus 11.2%, P < .0001) and intubation rates (18.5% versus 23.6%, P = .0009). Hemodialysis rate (7.2% versus 6.9%, P = .5) and length of stay (8.8 versus 9.6 days, P = .8) were similar between groups. Mortality was significantly lower in the bariatric surgery group for patients 18-64 years of age (5.9% versus 7.4%, P = .01) and ≥65 years of age (12.9% versus 17.9%, P = .0006). CONCLUSIONS: This retrospective cohort study found that inpatients with obesity and COVID-19 who had prior bariatric surgery had improved outcomes compared with a similar cohort without prior bariatric surgery. Further studies should examine mechanisms for the association between bariatric surgery and less severe COVID-19.

Characteristics and Outcomes of Women With COVID-19 Giving Birth at US Academic Centers During the COVID-19 Pandemic.

Importance: Prior studies on COVID-19 and pregnancy have reported higher rates of cesarean delivery and preterm birth and increased morbidity and mortality. Additional data encompassing a longer time period are needed. Objective: To examine characteristics and outcomes of a large US cohort of women who underwent childbirth with vs without COVID-19. Design, Setting, and Participants: This cohort study compared characteristics and outcomes of women (age ≥18 years) who underwent childbirth with vs without COVID-19 between March 1, 2020, and February 28, 2021, at 499 US academic medical centers or community affiliates. Follow-up was limited to in-hospital course and discharge destination. Childbirth was defined by clinical classification software procedural codes of 134-137. A diagnosis of COVID-19 was identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis of U07.1. Data were analyzed from April 1 to April 30, 2021. Exposures: The presence of a COVID-19 diagnosis using ICD-10. Main Outcomes and Measures: Analyses compared demographic characteristics, gestational age, and comorbidities. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, and discharge status. Continuous variables were analyzed using t test, and categorical variables were analyzed using χ2. Results: Among 869 079 women, 18 715 (2.2%) had COVID-19, and 850 364 (97.8%) did not. Most women were aged 18 to 30 years (11 550 women with COVID-19 [61.7%]; 447 534 women without COVID-19 [52.6%]) and were White (8060 White women [43.1%] in the COVID-19 cohort; 499 501 White women (58.7%) in the non-COVID-19 cohort). There was no significant increase in cesarean delivery among women with COVID-19 (6088 women [32.5%] vs 273 810 women [32.3%]; P = .57). Women with COVID-19 were more likely to have preterm birth (3072 women [16.4%] vs 97 967 women [11.5%]; P < .001). Women giving birth with COVID-19, compared with women without COVID-19, had significantly higher rates of ICU admission (977 women [5.2%] vs 7943 women [0.9%]; odds ratio [OR], 5.84 [95% CI, 5.46-6.25]; P < .001), respiratory intubation and mechanical ventilation (275 women [1.5%] vs 884 women [0.1%]; OR, 14.33 [95% CI, 12.50-16.42]; P < .001), and in-hospital mortality (24 women [0.1%] vs 71 [<0.01%]; OR, 15.38 [95% CI, 9.68-24.43]; P < .001). Conclusions and Relevance: This retrospective cohort study found that women with COVID-19 giving birth had higher rates of mortality, intubation, ICU admission, and preterm birth than women without COVID-19.

Male gender is a predictor of higher mortality in hospitalized adults with COVID-19.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic continues to be a global threat, with tremendous resources invested into identifying risk factors for severe COVID-19 illness. The objective of this study was to analyze the characteristics and outcomes of male compared to female adults with COVID-19 who required hospitalization within US academic centers. METHODS: Using the Vizient clinical database, discharge records of adults with a diagnosis of COVID-19 between March 1, 2020 and November 30, 2020 were reviewed. Outcome measures included demographics, characteristics, length of hospital stay, rate of respiratory intubation and mechanical ventilation, and rate of in-hospital mortality of male vs female according to age, race/ethnicity, and presence of preexisting comorbidities. RESULTS: Among adults with COVID-19, 161,206 were male while 146,804 were female. Adult males with COVID-19 were more likely to have hypertension (62.1% vs 59.6%, p <0.001%), diabetes (39.2% vs 36.0%, p <0.001%), renal failure (22.3% vs 18.1%, p <0.001%), congestive heart failure (15.3% vs 14.6%, p <0.001%), and liver disease (5.9% vs 4.5%, p <0.001%). Adult females with COVID-19 were more likely to be obese (32.3% vs 25.7%, p<0.001) and have chronic pulmonary disease (23.7% vs 18.1%, p <0.001). Gender was significantly different among races (p<0.001), and there was a lower proportion of males versus females in African American patients with COVID-19. Comparison in outcomes of male vs. female adults with COVID-19 is depicted in Table 2. Compared to females, males with COVID-19 had a higher rate of in-hospital mortality (13.8% vs 10.2%, respectively, p <0.001); a higher rate of respiratory intubation (21.4% vs 14.6%, p <0.001); and a longer length of hospital stay (9.5 ± 12.5 days vs. 7.8 ± 9.8 days, p<0.001). In-hospital mortality analyzed according to age groups, race/ethnicity, payers, and presence of preexisting comorbidities consistently showed higher death rate among males compared to females (Table 2). Adult males with COVID-19 were associated with higher odds of mortality compared to their female counterparts across all age groups, with the effect being most pronounced in the 18-30 age group (OR, 3.02 [95% CI, 2.41-3.78]). CONCLUSION: This large analysis of 308,010 COVID-19 adults hospitalized at US academic centers showed that males have a higher rate of respiratory intubation and longer length of hospital stay compared to females and have a higher death rate even when compared across age groups, race/ethnicity, payers, and comorbidity.

Improved outcomes over time for adult COVID-19 patients with acute respiratory distress syndrome or acute respiratory failure.

BACKGROUND: COVID-19's pulmonary manifestations are broad, ranging from pneumonia with no supplemental oxygen requirements to acute respiratory distress syndrome (ARDS) with acute respiratory failure (ARF). In response, new oxygenation strategies and therapeutics have been developed, but their large-scale effects on outcomes in severe COVID-19 patients remain unknown. Therefore, we aimed to examine the trends in mortality, mechanical ventilation, and cost over the first six months of the pandemic for adult COVID-19 patients in the US who developed ARDS or ARF. METHODS AND FINDINGS: The Vizient Clinical Data Base, a national database comprised of administrative, clinical, and financial data from academic medical centers, was queried for patients ≥ 18-years-old with COVID-19 and either ARDS or ARF admitted between 3/2020-8/2020. Demographics, mechanical ventilation, length of stay, total cost, mortality, and discharge status were collected. Mann-Kendall tests were used to assess for significant monotonic trends in total cost, mechanical ventilation, and mortality over time. Chi-square tests were used to compare mortality rates between March-May and June-August. 110,223 adult patients with COVID-19 ARDS or ARF were identified. Mean length of stay was 12.1±13.3 days and mean total cost was $35,991±32,496. Mechanical ventilation rates were 34.1% and in-hospital mortality was 22.5%. Mean cost trended downward over time (p = 0.02) from $55,275 (March) to $18,211 (August). Mechanical ventilation rates trended down (p<0.01) from 53.8% (March) to 20.3% (August). Overall mortality rates also decreased (p<0.01) from 28.4% (March) to 13.7% (August). Mortality rates in mechanically ventilated patients were similar over time (p = 0.45), but mortality in patients not requiring mechanical ventilation decreased from March-May compared to June-July (13.5% vs 4.6%, p<0.01). CONCLUSIONS: This study describes the outcomes of a large cohort with COVID-19 ARDS or ARF and the subsequent decrease in cost, mechanical ventilation, and mortality over the first 6 months of the pandemic in the US.

The impact of the novel coronavirus pandemic on gastrointestinal operative volume in the United States.

BACKGROUND: In March 2020, the Surgeon General recommended limiting elective procedures to prepare for the COVID-19 surge. We hypothesize a consequence of COVID-19 is reduced operative volume across the country. We aim to examine changes in volume of common gastrointestinal operations during COVID-19, including elective, urgent/emergent, and cancer operations. We also evaluate if hospitals with more COVID-19 admissions were most impacted. METHODS: The Vizient database was used to determine monthly operative volume from November 2019 to June 2020 for elective operations (hiatal hernia repairs, bariatric surgery), urgent operations (cholecystectomies, appendectomies, inguinal hernia repairs), and cancer operations (colectomies, gastrectomies, esophagectomies). COVID-19 admissions per hospital were also determined. November 2019-January 2020 was defined as "pre-COVID." The monthly reduction in volume from pre-COVID was calculated for each operation. The top quartile (25%) of hospitals with the most COVID admissions were also evaluated separately from hospitals with fewer COVID cases. Data were analyzed using analysis of variance. RESULTS: Data from 559 hospitals were analyzed. The volumes of all operations evaluated were significantly reduced during the pandemic except gastrectomies and esophagectomies for cancer. The greatest reduction in all operations was in April. In April, the volume of bariatric surgery reduced by 98% (P < 0.001), hiatal hernia repairs by 96% (P < 0.001), urgent cholecystectomies by 42% (P < 0.001), urgent inguinal hernia repairs by 40% (P < 0.001), urgent appendectomies by 24% (P < 0.001), and colectomies for cancer by 39% (P < 0.001). Hospitals with the most COVID-19 admissions had greater reductions in all operations than hospitals with fewer COVID cases. CONCLUSIONS: The coronavirus pandemic led to a significant reduction in volume of all gastrointestinal operations evaluated except gastrectomies and esophagectomies. While elective, non-cancer operations were most affected, urgent and some cancer operations also declined significantly. As COVID-19 continues to surge, Americans may suffer continued limited access to surgical care and a significant operative backlog may be forthcoming.

Analysis of COVID-19 Patients With Acute Respiratory Distress Syndrome Managed With Extracorporeal Membrane Oxygenation at US Academic Centers.

OBJECTIVE: This study analyzed the outcomes of COVID-19 patients with ARDS who were managed with extracorporeal membrane oxygenation (ECMO) across 155 US academic centers. SUMMARY BACKGROUND DATA: ECMO has been utilized in COVID-19 patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Early case series with the use of ECMO in these patients reported high mortality exceeding 90%. METHODS: Using ICD-10 codes, data of patients with COVID-19 with ARDS, managed with ECMO between April and September 2020, were analyzed using the Vizient clinical database. Outcomes measured included in-hospital mortality, hospital and ICU length of stay, and direct cost. For comparative purposes, the outcome of a subset of COVID-19 patients aged between 18 and 64 years and managed with versus without ECMO were examined. RESULTS: 1,182 patients with COVID-19 and ARDS received ECMO. In-hospital mortality was 45.9%, mean length of stay was 36.8 ±â€Š24.9 days, and mean ICU stay was 29.1 ±â€Š17.3 days. In-hospital mortality according to age group was 25.2% for 1 to 30 years; 42.2% for 31 to 50 years; 53.2% for 51 to 64 years; and 73.7% for ≥65 years. A subset analysis of COVID-19 patients, aged 18 to 64 years with ARDS requiring mechanical ventilation and managed with (n = 1113) vs without (n = 16,343) ECMO, showed relatively high in-hospital mortality for both groups (44.6% with ECMO vs 37.9% without ECMO). CONCLUSIONS: In this large US study of patients with COVID-19 and ARDS managed with ECMO, the in-hospital mortality is high but much lower than initial reports. Future research is needed to evaluate which patients with COVID-19 and ARDS would benefit from ECMO.

The Impact of COVID-19 on Volume of Inpatient Hospitalization Through General Medicine and Medicine Subspecialty Services at US Medical Centers.

As the coronavirus disease 2019 pandemic continues to impact hospital systems both in the United States and throughout the world, it is important to understand how the pandemic has impacted the volume of hospital admissions. Using the Vizient Inc (Chicago, IL) clinical databases, we analyzed inpatient hospital discharges from the general medicine service and its subspecialty services including cardiology, neonatology, pulmonary/critical care, oncology, psychiatry, and neurology between December 2019 and July 2020. We compared baseline discharge data to that of the first six months of the pandemic, from February to July 2020. We set the baseline as discharges by specialty from February 2019 through January 2020, averaged over the 12 months. Compared to baseline, by April 2020 the volume of general medicine hospital discharge was reduced by -20.2%, from 235,581 to 188,027 discharges. We found that while overall the number of discharges decreased from baseline, with a nadir in April 2020, pulmonary/critical care services had an increase in hospital discharge volume throughout the pandemic, from 7534 at baseline to 15,792 discharges in April. These findings are important for understanding health care use during the pandemic and ensuring proper allocation of resources and funding throughout the coronavirus disease 2019 pandemic.