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1.
Crit Care Explor ; 4(6): e0715, 2022 Jun.
Article in English | MEDLINE | ID: covidwho-1885271

ABSTRACT

Primary care providers (PCPs) receive limited information about their patients' ICU stays; we sought to understand what additional information PCPs desire to support patients' recovery following critical illness. DESIGN: Semistructured interviews with PCPs conducted between September 2020 and April 2021. SETTING: Academic health system with central quaternary-care hospital and associated Veterans Affairs medical center. SUBJECTS: Fourteen attending internal medicine or family medicine physicians working in seven clinics across Southeast Michigan (median, 10.5 yr in practice). MAIN OUTCOMES AND MEASURES: We analyzed using a modified Rigorous and Accelerated Data Reduction (RADaR) technique to identify gaps in current discharge summaries for patients with ICU stays, impacts of these gaps, and desired ICU-specific information. We employed RADaR to efficiently consolidate data in Excel Microsoft (Redmond, WA) tables across multiple formats (lists, themes, etc.). RESULTS: PCPs reported receiving limited ICU-specific information in hospital discharge summaries. PCPs often spent significant time reading inpatient records for additional information. Information desired included life-support interventions provided and duration (mechanical ventilation, dialysis, etc.), reasons for treatment decisions (code status changes, medication changes, etc.), and potential complications (delirium, dysphagia, postintensive care syndrome, etc.). Pervasive discharge gaps (ongoing needs, incidental findings, etc.) were described as worse among patients with ICU stays due to more complex illness and required interventions. Insufficient information was felt to lead to incomplete follow-up on critical issues, PCP frustration, and patient harm. PCPs stated that the COVID-19 pandemic exacerbated gaps due to decreased staffing, limited visitation policies, and reliance on telehealth follow-up visits. CONCLUSIONS AND RELEVANCE: Our results identified key data elements sought by PCPs about patients' ICU stays and suggest opportunities to improve care through developing tools/templates to provide PCPs with ICU-specific information for outpatient follow-up.

2.
Ann Intern Med ; 175(4): 505-512, 2022 04.
Article in English | MEDLINE | ID: covidwho-1818638

ABSTRACT

BACKGROUND: Although disparities in COVID-19 outcomes have been observed, factors contributing to these differences are not well understood. OBJECTIVE: To determine whether COVID-19 hospitalization outcomes are related to neighborhood-level social vulnerability, independent of patient-level clinical factors. DESIGN: Pooled cross-sectional study of prospectively collected data. SETTING: 38 Michigan hospitals. PATIENTS: Adults older than 18 years hospitalized for COVID-19 in a participating site between March and December 2020. MEASUREMENTS: COVID-19 outcomes included acute organ dysfunction, organ failure, invasive mechanical ventilation, intensive care unit stay, death, and discharge disposition. Social vulnerability was measured by the social vulnerability index (SVI), a composite measure of social disadvantage. RESULTS: Compared with patients in low-vulnerability ZIP codes, those living in high-vulnerability ZIP codes were more frequently treated in the intensive care unit (29.0% vs. 24.5%); more frequently received mechanical ventilation (19.3% vs. 14.2%); and experienced higher rates of organ dysfunction (51.9% vs. 48.6%), organ failure (54.7% vs. 51.6%), and in-hospital death (19.4% vs. 16.7%). In mixed-effects regression analyses accounting for age, sex, and comorbid conditions, an increase in a patient's neighborhood SVI by 0.25 (1 quartile) was associated with greater likelihood of mechanical ventilation (increase of 2.1 percentage points), acute organ dysfunction (increase of 2.8 percentage points), and acute organ failure (increase of 2.8 percentage points) but was not associated with intensive care unit stay, mortality, or discharge disposition. LIMITATION: Observational data focused on hospitalizations in a single state. CONCLUSION: Hospitalized patients with COVID-19 from socially vulnerable neighborhoods presented with greater illness severity and required more intensive treatment, but once hospitalized they did not experience differences in hospital mortality or discharge disposition. Policies that target socially vulnerable neighborhoods and access to COVID-19 care may help ameliorate health disparities. PRIMARY FUNDING SOURCE: Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships Program, the Michigan Public Health Institute, and the Michigan Department of Health & Human Services.


Subject(s)
COVID-19 , Adult , COVID-19/epidemiology , COVID-19/therapy , Cross-Sectional Studies , Hospital Mortality , Hospitalization , Humans , Multiple Organ Failure , Retrospective Studies , SARS-CoV-2
3.
Clinics in Chest Medicine ; 2022.
Article in English | ScienceDirect | ID: covidwho-1797105
4.
Infect Dis Ther ; 11(2): 887-898, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1787898

ABSTRACT

INTRODUCTION: While guidelines stronglyrecommend dexamethasone in critical COVID-19, the optimal threshold to initiate corticosteroids in non-critically ill patients with COVID-19 remains unclear. Using data from a state-wide COVID-19 registry, we evaluated the effectiveness of early corticosteroids for preventing clinical deterioration among non-critically ill patients hospitalized for COVID-19 and receiving non-invasive oxygen therapy. METHODS: This was a target trial using observational data from patients hospitalized for COVID-19 at 39 hospitals participating in the MI-COVID19 registry between March 16, 2020 and August 24, 2020. We studied the impact of corticosteroids initiated within 2 calendar days of hospitalization ("early steroids") versus no early steroids among non-ICU patients with laboratory-confirmed SARS-CoV2 receiving non-invasive supplemental oxygen therapy. Our primary outcome was a composite of in-hospital mortality, transfer to intensive care, and receipt of invasive mechanical ventilation. We used inverse probability of treatment weighting (IPTW) and propensity score-weighted regression to measure the association of early steroids and outcomes. RESULTS: Among 1002 patients meeting study criteria, 231 (23.1%) received early steroids. After IPTW, to balance potential confounders between the treatment groups, early steroids were not associated with a decrease in the composite outcome (aOR 1.1, 95%CI 0.8-1.6) or in any components of the primary outcome. CONCLUSION: We found no evidence that early corticosteroid therapy prevents clinical deterioration among hospitalized non-critically ill COVID-19 patients receiving non-invasive oxygen therapy. Further studies are needed to determine the optimal threshold for initiating corticosteroids in this population.

5.
Crit Care Nurse ; 42(2): 56-61, 2022 Apr 01.
Article in English | MEDLINE | ID: covidwho-1776399

ABSTRACT

BACKGROUND: In patients receiving mechanical ventilation, spontaneous awakening trials reduce morbidity and mortality when paired with spontaneous breathing trials. However, spontaneous awakening trials are not performed every day they are indicated and little is known about spontaneous awakening trial protocol use in cardiac intensive care units. LOCAL PROBLEM: Spontaneous awakening trial completion rate at the study institution was low and no trial protocol was regularly used. METHODS: A preintervention-postintervention retrospective cohort study was performed in adult patients with at least 24 hours of invasive mechanical ventilation in Michigan Medicine's cardiac intensive care unit. Patients with SARS-CoV-2 infection were excluded. Data included demographics, sedation, mechanical ventilation duration, and in-hospital mortality. A nurse-driven spontaneous awakening trial protocol modified for the cardiac intensive care unit was implemented in October 2020. RESULTS: Compared with the preintervention cohort (n = 29, May through July 2020), the postintervention cohort (n = 27, October 2020 through February 2021) had a higher ratio of number of trials performed to number of days eligible for trial (0.91 vs 0.52; P < .01). Median continuous sedative infusion duration was shorter after intervention (2.3 vs 3.6 days; P = .02). Median mechanical ventilation duration (3.8 vs 4.7 days; P = .18) and mortality (41% vs 41%; P = .95) were similar between groups. CONCLUSIONS: Spontaneous awakening trial protocol implementation led to a higher trial completion rate and a shorter duration of continuous sedative infusion. Larger studies are needed to assess the impact of protocolized spontaneous awakening trials on cardiac intensive care unit patient outcomes.


Subject(s)
COVID-19 , Adult , Humans , Intensive Care Units , Retrospective Studies , SARS-CoV-2 , Ventilator Weaning
6.
Infect Control Hosp Epidemiol ; : 1-10, 2021 Jul 26.
Article in English | MEDLINE | ID: covidwho-1764088

ABSTRACT

BACKGROUND: We sought to determine the incidence of community-onset and hospital-acquired coinfection in patients hospitalized with coronavirus disease 2019 (COVID-19) and to evaluate associated predictors and outcomes. METHODS: In this multicenter retrospective cohort study of patients hospitalized for COVID-19 from March 2020 to August 2020 across 38 Michigan hospitals, we assessed prevalence, predictors, and outcomes of community-onset and hospital-acquired coinfections. In-hospital and 60-day mortality, readmission, discharge to long-term care facility (LTCF), and mechanical ventilation duration were assessed for patients with versus without coinfection. RESULTS: Of 2,205 patients with COVID-19, 141 (6.4%) had a coinfection: 3.0% community onset and 3.4% hospital acquired. Of patients without coinfection, 64.9% received antibiotics. Community-onset coinfection predictors included admission from an LTCF (OR, 3.98; 95% CI, 2.34-6.76; P < .001) and admission to intensive care (OR, 4.34; 95% CI, 2.87-6.55; P < .001). Hospital-acquired coinfection predictors included fever (OR, 2.46; 95% CI, 1.15-5.27; P = .02) and advanced respiratory support (OR, 40.72; 95% CI, 13.49-122.93; P < .001). Patients with (vs without) community-onset coinfection had longer mechanical ventilation (OR, 3.31; 95% CI, 1.67-6.56; P = .001) and higher in-hospital mortality (OR, 1.90; 95% CI, 1.06-3.40; P = .03) and 60-day mortality (OR, 1.86; 95% CI, 1.05-3.29; P = .03). Patients with (vs without) hospital-acquired coinfection had higher discharge to LTCF (OR, 8.48; 95% CI, 3.30-21.76; P < .001), in-hospital mortality (OR, 4.17; 95% CI, 2.37-7.33; P ≤ .001), and 60-day mortality (OR, 3.66; 95% CI, 2.11-6.33; P ≤ .001). CONCLUSION: Despite community-onset and hospital-acquired coinfection being uncommon, most patients hospitalized with COVID-19 received antibiotics. Admission from LTCF and to ICU were associated with increased risk of community-onset coinfection. Future studies should prospectively validate predictors of COVID-19 coinfection to facilitate the reduction of antibiotic use.

8.
Crit Care Med ; 49(11): 1974-1982, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1475880
9.
Crit Care Med ; 49(11): 1986-1988, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1467430
10.
Medicine (Baltimore) ; 100(40): e27422, 2021 Oct 08.
Article in English | MEDLINE | ID: covidwho-1462561

ABSTRACT

ABSTRACT: As severe acute respiratory syndrome coronavirus 2 continues to spread, easy-to-use risk models that predict hospital mortality can assist in clinical decision making and triage. We aimed to develop a risk score model for in-hospital mortality in patients hospitalized with 2019 novel coronavirus (COVID-19) that was robust across hospitals and used clinical factors that are readily available and measured standardly across hospitals.In this retrospective observational study, we developed a risk score model using data collected by trained abstractors for patients in 20 diverse hospitals across the state of Michigan (Mi-COVID19) who were discharged between March 5, 2020 and August 14, 2020. Patients who tested positive for severe acute respiratory syndrome coronavirus 2 during hospitalization or were discharged with an ICD-10 code for COVID-19 (U07.1) were included. We employed an iterative forward selection approach to consider the inclusion of 145 potential risk factors available at hospital presentation. Model performance was externally validated with patients from 19 hospitals in the Mi-COVID19 registry not used in model development. We shared the model in an easy-to-use online application that allows the user to predict in-hospital mortality risk for a patient if they have any subset of the variables in the final model.Two thousand one hundred and ninety-three patients in the Mi-COVID19 registry met our inclusion criteria. The derivation and validation sets ultimately included 1690 and 398 patients, respectively, with mortality rates of 19.6% and 18.6%, respectively. The average age of participants in the study after exclusions was 64 years old, and the participants were 48% female, 49% Black, and 87% non-Hispanic. Our final model includes the patient's age, first recorded respiratory rate, first recorded pulse oximetry, highest creatinine level on day of presentation, and hospital's COVID-19 mortality rate. No other factors showed sufficient incremental model improvement to warrant inclusion. The area under the receiver operating characteristics curve for the derivation and validation sets were .796 (95% confidence interval, .767-.826) and .829 (95% confidence interval, .782-.876) respectively.We conclude that the risk of in-hospital mortality in COVID-19 patients can be reliably estimated using a few factors, which are standardly measured and available to physicians very early in a hospital encounter.


Subject(s)
COVID-19/mortality , Hospital Mortality/trends , Age Factors , Aged , Aged, 80 and over , Body Mass Index , Comorbidity , Creatinine/blood , Female , Health Behavior , Humans , Logistic Models , Male , Michigan/epidemiology , Middle Aged , Oximetry , Prognosis , ROC Curve , Retrospective Studies , Risk Assessment , Risk Factors , SARS-CoV-2 , Severity of Illness Index , Sex Factors , Socioeconomic Factors
11.
Medicine (Baltimore) ; 100(37): e27265, 2021 Sep 17.
Article in English | MEDLINE | ID: covidwho-1434547

ABSTRACT

ABSTRACT: During the spring 2020 COVID-19 surge, hospitals in Southeast Michigan were overwhelmed, and hospital beds were limited. However, it is unknown whether threshold for hospital admission varied across hospitals or over time.Using a statewide registry, we performed a retrospective cohort study. We identified adult patients hospitalized with COVID-19 in Southeast Michigan (3/1/2020-6/1/2020). We classified disease severity on admission using the World Health Organization (WHO) ordinal scale. Our primary measure of interest was the proportion of patients admitted on room air. We also determined the proportion without acute organ dysfunction on admission or any point during hospitalization. We quantified variation across hospitals and over time by half-month epochs.Among 1315 hospitalizations across 22 hospitals, 57.3% (754/1,315) were admitted on room air, and 26.1% (343/1,315) remained on room air for the duration of hospitalization. Across hospitals, the proportion of COVID-19 hospitalizations admitted on room air varied from 32.3% to 80.0%. Across half-month epochs, the proportion ranged from 49.4% to 69.4% and nadired in early April 2020. Among patients admitted on room air, 75.1% (566/754) had no acute organ dysfunction on admission, and 35.3% (266/754) never developed acute organ dysfunction at any point during hospitalization; there was marked variation in both proportions across hospitals. In-hospital mortality was 13.7% for patients admitted on room air vs 26.3% for patients requiring nasal cannula oxygen.Among patients hospitalized with COVID-19 during the spring 2020 surge in Southeast Michigan, more than half were on room air and a third had no acute organ dysfunction upon admission, but experienced high rates of disease progression and in-hospital mortality.


Subject(s)
COVID-19/complications , Hospitalization/statistics & numerical data , Aged , Cohort Studies , Female , Humans , Male , Michigan , Middle Aged , Severity of Illness Index , Time Factors
13.
Annu Rev Med ; 73: 113-127, 2022 01 27.
Article in English | MEDLINE | ID: covidwho-1367487

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created a global pandemic. Beyond the well-described respiratory manifestations, SARS-CoV-2 may cause a variety of neurologic complications, including headaches, alteration in taste and smell, encephalopathy, cerebrovascular disease, myopathy, psychiatric diseases, and ocular disorders. Herein we describe SARS-CoV-2's mechanism of neuroinvasion and the epidemiology, outcomes, and treatments for neurologic manifestations of COVID-19.


Subject(s)
COVID-19 , Nervous System Diseases , Humans , Nervous System Diseases/etiology , Pandemics , SARS-CoV-2
14.
Clin Infect Dis ; 72(10): e533-e541, 2021 05 18.
Article in English | MEDLINE | ID: covidwho-1232185

ABSTRACT

BACKGROUND: Antibacterials may be initiated out of concern for bacterial coinfection in coronavirus disease 2019 (COVID-19). We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial coinfections in hospitalized patients with COVID-19. METHODS: A randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020 and 6/18/2020. Data were collected on early (within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial coinfections (positive microbiologic test ≤3 days). Poisson generalized estimating equation models were used to assess predictors. RESULTS: Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27% to 84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00-1.08] per 10 years); had a lower body mass index (ARR: 0.99 [0.99-1.00] per kg/m2), more severe illness (eg, severe sepsis; ARR: 1.16 [1.07-1.27]), a lobar infiltrate (ARR: 1.21 [1.04-1.42]); or were admitted to a for-profit hospital (ARR: 1.30 [1.15-1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs April [85.2%, 628/737], P < .001) and empiric antibacterial use (ARR: 0.71 [0.63-0.81] April vs March) decreased. CONCLUSIONS: The prevalence of confirmed community-onset bacterial coinfections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.


Subject(s)
COVID-19 , Coinfection , Anti-Bacterial Agents/therapeutic use , Cohort Studies , Coinfection/drug therapy , Coinfection/epidemiology , Hospitalization , Hospitals , Humans , Michigan , SARS-CoV-2
15.
JAMA ; 325(15): 1511-1512, 2021 04 20.
Article in English | MEDLINE | ID: covidwho-1222576
17.
JAMA ; 325(15): 1511-1512, 2021 04 20.
Article in English | MEDLINE | ID: covidwho-1136892
18.
Crit Care Med ; 49(2): 353-355, 2021 02 01.
Article in English | MEDLINE | ID: covidwho-1087826

Subject(s)
Sepsis , Humans
20.
Crit Care Med ; 49(4): 598-622, 2021 04 01.
Article in English | MEDLINE | ID: covidwho-1085323

ABSTRACT

OBJECTIVES: To identify research priorities in the management, pathophysiology, and host response of coronavirus disease 2019 in critically ill patients. DESIGN: The Surviving Sepsis Research Committee, a multiprofessional group of 17 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine, was virtually convened during the coronavirus disease 2019 pandemic. The committee iteratively developed the recommendations and subsequent document. METHODS: Each committee member submitted a list of what they believed were the most important priorities for coronavirus disease 2019 research. The entire committee voted on 58 submitted questions to determine top priorities for coronavirus disease 2019 research. RESULTS: The Surviving Sepsis Research Committee provides 13 priorities for coronavirus disease 2019. Of these, the top six priorities were identified and include the following questions: 1) Should the approach to ventilator management differ from the standard approach in patients with acute hypoxic respiratory failure?, 2) Can the host response be modulated for therapeutic benefit?, 3) What specific cells are directly targeted by severe acute respiratory syndrome coronavirus 2, and how do these cells respond?, 4) Can early data be used to predict outcomes of coronavirus disease 2019 and, by extension, to guide therapies?, 5) What is the role of prone positioning and noninvasive ventilation in nonventilated patients with coronavirus disease?, and 6) Which interventions are best to use for viral load modulation and when should they be given? CONCLUSIONS: Although knowledge of both biology and treatment has increased exponentially in the first year of the coronavirus disease 2019 pandemic, significant knowledge gaps remain. The research priorities identified represent a roadmap for investigation in coronavirus disease 2019.


Subject(s)
COVID-19 , Critical Care , Research , Sepsis/therapy , Humans
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