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2.
Sci Rep ; 13(1): 9064, 2023 06 04.
Article in English | MEDLINE | ID: covidwho-20240546

ABSTRACT

Prognostic scales may help to optimize the use of hospital resources, which may be of prime interest in the context of a fast spreading pandemics. Nonetheless, such tools are underdeveloped in the context of COVID-19. In the present article we asked whether accurate prognostic scales could be developed to optimize the use of hospital resources. We retrospectively studied 467 files of hospitalized patients after COVID-19. The odds ratios for 16 different biomarkers were calculated, those that were significantly associated were screened by a Pearson's correlation, and such index was used to establish the mathematical function for each marker. The scales to predict the need for hospitalization, intensive-care requirement and mortality had enhanced sensitivities (0.91 CI 0.87-0.94; 0.96 CI 0.94-0.98; 0.96 CI 0.94-0.98; all with p < 0.0001) and specificities (0.74 CI 0.62-0.83; 0.92 CI 0.87-0.96 and 0.91 CI 0.86-0.94; all with p < 0.0001). Interestingly, when a different population was assayed, these parameters did not change considerably. These results show a novel approach to establish the mathematical function of a marker in the development of highly sensitive prognostic tools, which in this case, may aid in the optimization of hospital resources. An online version of the three algorithms can be found at: http://benepachuca.no-ip.org/covid/index.php.


Subject(s)
COVID-19 , Humans , COVID-19/diagnosis , SARS-CoV-2 , Retrospective Studies , Intensive Care Units , Hospitalization , Critical Care , Biomarkers , Probability
3.
Medicine (Baltimore) ; 102(21): e33870, 2023 May 26.
Article in English | MEDLINE | ID: covidwho-20239240

ABSTRACT

RATIONALE: The standardization, individualization, and rationalization of intensive care and treatment for severe patients have improved. However, the combination of corona virus disease 2019 (COVID-19) and cerebral infarction presents new challenges beyond routine nursing care. PATIENT CONCERNS AND DIAGNOSES: This paper examines the rehabilitation nursing of patients with both COVID-19 and cerebral infarction as an example. It is necessary to develop a nursing plan for COVID-19 patients and implement early rehabilitation nursing for cerebral infarction patients. INTERVENTIONS: Timely rehabilitation nursing intervention is essential to enhance treatment outcomes and promote patient rehabilitation. After 20 days of rehabilitation nursing treatment, patients showed significant improvement in visual analogue scale score, drinking test, and upper and lower limb muscle strength. OUTCOMES: Treatment outcomes for complications, motor function, and daily activities also improved significantly. LESSONS: Critical care and rehabilitation specialist care play a positive role in ensuring patient safety and improving their quality of life by adapting measures to local conditions and the timing of care.


Subject(s)
COVID-19 , Humans , COVID-19/complications , Quality of Life , Cerebral Infarction/complications , Treatment Outcome , Critical Care
4.
Crit Care Clin ; 39(3): 479-502, 2023 Jul.
Article in English | MEDLINE | ID: covidwho-20237860

ABSTRACT

Critically ill patients are at risk of post-intensive care syndrome, including physical, cognitive, and psychological sequelae. Physiotherapists are rehabilitation experts who focus on restoring strength, physical function, and exercise capacity. Critical care has evolved from a culture of deep sedation and bed rest to one of awakening and early mobility; physiotherapeutic interventions have developed to address patients' rehabilitation needs. Physiotherapists are assuming more prominent roles in clinical and research leadership, with opportunities for wider interdisciplinary collaboration. This paper reviews the evolution of critical care from a rehabilitation perspective, highlights relevant research milestones, and proposes future opportunities for improving survivorship outcomes.


Subject(s)
Bed Rest , Early Ambulation , Humans , Intensive Care Units , Physical Therapy Modalities , Critical Care , Critical Illness/rehabilitation
5.
Prehosp Disaster Med ; 38(3): 311-318, 2023 Jun.
Article in English | MEDLINE | ID: covidwho-20237774

ABSTRACT

INTRODUCTION: The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland's (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care. METHODS: The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation. RESULTS: Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide. CONCLUSION: The C4 has played an integral role in the State of Maryland's pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.


Subject(s)
COVID-19 , Child , Humans , Maryland/epidemiology , COVID-19/epidemiology , Critical Illness/therapy , Pandemics , Retrospective Studies , Critical Care
6.
Lancet ; 401(10376): 568-576, 2023 02 18.
Article in English | MEDLINE | ID: covidwho-20236778

ABSTRACT

BACKGROUND: On the basis of low-quality evidence, international critical care nutrition guidelines recommend a wide range of protein doses. The effect of delivering high-dose protein during critical illness is unknown. We aimed to test the hypothesis that a higher dose of protein provided to critically ill patients would improve their clinical outcomes. METHODS: This international, investigator-initiated, pragmatic, registry-based, single-blinded, randomised trial was undertaken in 85 intensive care units (ICUs) across 16 countries. We enrolled nutritionally high-risk adults (≥18 years) undergoing mechanical ventilation to compare prescribing high-dose protein (≥2·2 g/kg per day) with usual dose protein (≤1·2 g/kg per day) started within 96 h of ICU admission and continued for up to 28 days or death or transition to oral feeding. Participants were randomly allocated (1:1) to high-dose protein or usual dose protein, stratified by site. As site personnel were involved in both prescribing and delivering protein dose, it was not possible to blind clinicians, but patients were not made aware of the treatment assignment. The primary efficacy outcome was time-to-discharge-alive from hospital up to 60 days after ICU admission and the secondary outcome was 60-day morality. Patients were analysed in the group to which they were randomly assigned regardless of study compliance, although patients who dropped out of the study before receiving the study intervention were excluded. This study is registered with ClinicalTrials.gov, NCT03160547. FINDINGS: Between Jan 17, 2018, and Dec 3, 2021, 1329 patients were randomised and 1301 (97·9%) were included in the analysis (645 in the high-dose protein group and 656 in usual dose group). By 60 days after randomisation, the cumulative incidence of alive hospital discharge was 46·1% (95 CI 42·0%-50·1%) in the high-dose compared with 50·2% (46·0%-54·3%) in the usual dose protein group (hazard ratio 0·91, 95% CI 0·77-1·07; p=0·27). The 60-day mortality rate was 34·6% (222 of 642) in the high dose protein group compared with 32·1% (208 of 648) in the usual dose protein group (relative risk 1·08, 95% CI 0·92-1·26). There appeared to be a subgroup effect with higher protein provision being particularly harmful in patients with acute kidney injury and higher organ failure scores at baseline. INTERPRETATION: Delivery of higher doses of protein to mechanically ventilated critically ill patients did not improve the time-to-discharge-alive from hospital and might have worsened outcomes for patients with acute kidney injury and high organ failure scores. FUNDING: None.


Subject(s)
Critical Care , Critical Illness , Adult , Humans , Critical Illness/therapy , Intensive Care Units , Hospitalization , Respiration, Artificial , Registries
7.
Crit Care Clin ; 39(3): 603-625, 2023 Jul.
Article in English | MEDLINE | ID: covidwho-20236490

ABSTRACT

Critical care units-designed for concentrated and specialized care-came from multiple parallel advances in medical, surgical, and nursing techniques and training taking advantage of new therapeutic technologies. Regulatory requirements and government policy impacted design and practice. After WWII, medical practice and education promoted further specialization. Hospitals offered newer, more extreme, and specialized surgeries and anesthesia enabled more complex procedures. ICUs developed in the 1950s, providing a recovery room's level of observation and specialized nursing to serve the critically ill, whether medical or surgical.


Subject(s)
Critical Care , Intensive Care Units , Humans , Critical Illness , Technology
8.
Rev Lat Am Enfermagem ; 31: e3861, 2023.
Article in English, Portuguese, Spanish | MEDLINE | ID: covidwho-20236068

ABSTRACT

OBJECTIVE: to evaluate nursing professionals and patient safety culture during the professional performance in the care of suspected or infected patients with COVID-19. METHOD: a cross-sectional study carried out with 90 professionals from critical care units of two teaching hospitals. An instrument for sociodemographic characterization and health conditions was used, in addition to the constructs "Nursing professional and patient safety" and the Hospital Survey on Patient Safety Culture. Univariate analyzes were performed between the diagnosis of COVID-19 and the characteristics of Nursing professionals, applying Kendell's correlation between the constructs. RESULTS: the COVID-19 diagnosis presented a significant statistical difference between nursing professionals that worked for more than six years at the critical care unit (p=0.020) and the items of the construct "Nursing professional and patient safety" regarding the doubts about how to remove the personal protective equipment (p=0.013) and safety flow (p=0,021). The dimensions 2 (p=0.003), 3 (p=0.009), 4 (p=0.013), 6 (p<0.001), and 9 (p=0.024) of the Hospital Survey on Patient Safety Culture were associated with the accomplishment of training. CONCLUSION: a higher professional nursing experience time was associated with non-infection by COVID-19. The perception of the safety culture of the patient was related to the accomplishment of training.


Subject(s)
COVID-19 , Humans , COVID-19/epidemiology , COVID-19 Testing , Cross-Sectional Studies , Pandemics , Patient Safety , Critical Care
9.
BMC Med Educ ; 23(1): 371, 2023 May 24.
Article in English | MEDLINE | ID: covidwho-20235839

ABSTRACT

BACKGROUND: The COVID-19 pandemic has changed the way medical education is delivered. The purpose of this study was to assess the impact of the COVID-19 pandemic on the education and procedural volume of critical care and pulmonary critical care fellows. METHODS: We conducted a cross-sectional, internet-based, voluntary, anonymous, national survey of adult critical care fellows and academic attending physicians in critical care and pulmonary critical care fellowship programs in the United States between December 2020 and February 2021. Survey questions covered both didactic and non-didactic aspects of education and procedural volumes. Answers were ranked on a 5-point Likert scale. Survey responses were summarized by frequency with percentage. Differences between the responses of fellows and attendings were assessed with the Fisher's exact or Chi-Square test, using Stata 16 software (StataCorp LLC, College Station, TX). RESULTS: Seventy four individuals responded to the survey; the majority (70.3%) were male; less than one-third (28.4%) female. Respondents were evenly split among fellows (52.7%) and attendings (47.3%). 41.9% of survey respondents were from the authors' home institution, with a response rate of 32.6%. Almost two-thirds (62.2%) reported that fellows spend more time in the ICU since the onset of the pandemic. The majority noted that fellows insert more central venous catheters (52.7%) and arterial lines (58.1%), but perform fewer bronchoscopies (59.5%). The impact on endotracheal intubations was mixed: almost half of respondents (45.9%) reported fewer intubations, about one-third (35.1%) more intubations. Almost all respondents (93.0%) described fewer workshops; and one-third (36.1%) fewer didactic lectures. The majority (71.2%) noted less time available for research and quality improvement projects; half (50.7%) noted less bedside teaching by faculty and more than one-third (37.0%) less fellow interaction with faculty. Almost one-half of respondents (45.2%) reported an increase in fellows' weekly work hours. CONCLUSION: The pandemic has caused a decrease in scholarly and didactic activities of critical care and pulmonary critical care fellows. Fellows spend more time in ICU rotations, insert more central and arterial lines, but perform fewer intubations and bronchoscopies. This survey provides insights into changes that have occurred in the training of critical care and pulmonary critical care fellows since the onset of the COVID-19 pandemic.


Subject(s)
COVID-19 , Pandemics , Adult , Female , Male , Humans , Cross-Sectional Studies , COVID-19/epidemiology , Educational Status , Critical Care
10.
Int J Environ Res Public Health ; 20(11)2023 Jun 01.
Article in English | MEDLINE | ID: covidwho-20232822

ABSTRACT

The health crisis has had a strong impact on intensive care units. The objective of this study was to investigate the experience of resuscitation physicians during the COVID-19 health crisis to understand the associated determinants of quality of life, burnout, and brownout. This qualitative, longitudinal study covered two periods (T1, February 2021, and T2, May 2021). The data were collected in individual semi-directed interviews with 17 intensive care physicians (ICPs) (T1). Nine of the latter also participated in a second interview (T2). The data were examined using grounded theory analysis. We identified a multiplication of burnout and brownout indicators and factors already known in intensive care. In addition, burnout and brownout indicators and factors specific to the COVID-19 crisis were added. The evolution of professional practices has disrupted the professional identity, the meaning of work, and the boundaries between private and professional life, leading to a brownout and blur-out syndrome. The added value of our study lies in identifying the positive effects of the crisis in the professional domain. Our study revealed indicators and factors of burnout and brownout associated with the crisis among ICPs. Finally, it highlights the beneficial effects of the COVID-19 crisis on work.


Subject(s)
Burnout, Professional , COVID-19 , Physicians , Humans , Quality of Life , Longitudinal Studies , COVID-19/epidemiology , Burnout, Psychological , Burnout, Professional/epidemiology , Critical Care , Surveys and Questionnaires
11.
Zhongguo Zhong Yao Za Zhi ; 48(10): 2606-2612, 2023 May.
Article in Chinese | MEDLINE | ID: covidwho-20244902

ABSTRACT

Xiao Chaihu Decoction combined with Maxing Shigan Decoction is a classic herbal formula. All of them are derived from Treatise on Cold Damage(Shang Han Lun) by ZHANG Zhong-jing. This combination has the effects of harmonizing lesser yang, relieving exterior syndrome, clearing lung heat, and relieving panting. It is mainly used for treating the disease involving the triple-Yang combination of diseases and accumulation of pathogenic heat in the lung. Xiao Chaihu Decoction combined with Maxing Shigan Decoction is a classic combination for the treatment of exogenous diseases involving the triple-Yang combination. They are commonly used in exogenous diseases, especially in the north of China. This combination is also the main treatment strategy for coronavirus disease 2019(COVID-19) accompanied by fever and cough. Maxing Shigan Decoction is a classical herbal formula for treating the syndrome of phlegm-heat obstructing the lung. "Dyspnea after sweating" suggests the accumulation of pathogenic heat in the lung. Patients with mild symptoms may develop cough and asthma along with forehead sweating, and those in critical severe may develop whole-body sweating, especially the front chest. Modern medicine believes that the above situation is related to lung infection. "Mild fever" refers to syndromes rather than pathogenesis. It does not mean that the heat syndrome is not heavy, instead, it suggests that severe heat and inflammation have occurred. The indications of Xiao Chaihu Decoction combined with Maxing Shigan Decoction are as follows.(1) In terms of diseases, it is suitable for the treatment of viral pneumonia, bronchopneumonia, lobar pneumonia, mycoplasma pneumonia, COVID-19 infection, measles with pneumonia, severe acute respiratory syndrome(SARS), avian influenza, H1N1 influenza, chronic obstructive pulmonary disease with acute exacerbation, pertussis, and other influenza and pneumonia.(2) In terms of syndromes, it can be used for the syndromes of bitter mouth, dry pharynx, vertigo, loss of appetite, vexation, vomiting, and fullness and discomfort in the chest and hypochondrium. It can also be used to treat alternate attacks of chill and fever and different degrees of fever, as well as chest tightness, cough, asthma, expectoration, dry mouth, wanting cold drinks, feeling agitated, sweating, yellow urine, dry stool, red tongue, yellow or white fur, and floating, smooth, and powerful pulse, especially the right wrist pulse.


Subject(s)
Asthma , COVID-19 , Drugs, Chinese Herbal , Influenza A Virus, H1N1 Subtype , Influenza, Human , Pulmonary Disease, Chronic Obstructive , Animals , Humans , Cough , Syndrome , Drugs, Chinese Herbal/therapeutic use , Drugs, Chinese Herbal/pharmacology , Lung , Pulmonary Disease, Chronic Obstructive/drug therapy , Critical Care , Medicine, Chinese Traditional
13.
Ter Arkh ; 94(11): 1225-1233, 2022 Dec 26.
Article in Russian | MEDLINE | ID: covidwho-20243248

ABSTRACT

AIM: To conduct a retrospective assessment of the clinical and laboratory data of patients with severe forms of COVID-19 hospitalized in the intensive care and intensive care unit, in order to assess the contribution of various indicators to the likelihood of death. MATERIALS AND METHODS: A retrospective assessment of data on 224 patients with severe COVID-19 admitted to the intensive care unit was carried out. The analysis included the data of biochemical, clinical blood tests, coagulograms, indicators of the inflammatory response. When transferring to the intensive care units (ICU), the indicators of the formalized SOFA and APACHE scales were recorded. Anthropometric and demographic data were downloaded separately. RESULTS: Analysis of obtained data, showed that only one demographic feature (age) and a fairly large number of laboratory parameters can serve as possible markers of an unfavorable prognosis. We identified 12 laboratory features the best in terms of prediction: procalcitonin, lymphocytes (absolute value), sodium (ABS), creatinine, lactate (ABS), D-dimer, oxygenation index, direct bilirubin, urea, hemoglobin, C-reactive protein, age, LDH. The combination of these features allows to provide the quality of the forecast at the level of AUC=0.85, while the known scales provided less efficiency (APACHE: AUC=0.78, SOFA: AUC=0.74). CONCLUSION: Forecasting the outcome of the course of COVID-19 in patients in ICU is relevant not only from the position of adequate distribution of treatment measures, but also from the point of view of understanding the pathogenetic mechanisms of the development of the disease.


Subject(s)
COVID-19 , Sepsis , Humans , COVID-19/diagnosis , COVID-19/epidemiology , Retrospective Studies , Intensive Care Units , Critical Care , Prognosis , ROC Curve
14.
Crit Care Clin ; 39(3): 465-477, 2023 Jul.
Article in English | MEDLINE | ID: covidwho-20241898

ABSTRACT

Brain dysfunction during critical illness (ie, delirium and coma) is extremely common, and its lasting effect has only become increasingly understood in the last two decades. Brain dysfunction in the intensive care unit (ICU) is an independent predictor of both increased mortality and long-term impairments in cognition among survivors. As critical care medicine has grown, important insights regarding brain dysfunction in the ICU have shaped our practice including the importance of light sedation and the avoidance of deliriogenic drugs such as benzodiazepines. Best practices are now strategically incorporated in targeted bundles of care like the ICU Liberation Campaign's ABCDEF Bundle.


Subject(s)
Critical Illness , Intensive Care Units , Humans , Critical Illness/therapy , Critical Care , Coma , Brain
15.
AMIA Annu Symp Proc ; 2022: 130-139, 2022.
Article in English | MEDLINE | ID: covidwho-20232747

ABSTRACT

Machine learning can be used to identify relevant trajectory shape features for improved predictive risk modeling, which can help inform decisions for individualized patient management in intensive care during COVID-19 outbreaks. We present explainable random forests to dynamically predict next day mortality risk in COVID -19 positive and negative patients admitted to the Mount Sinai Health System between March 1st and June 8th, 2020 using patient time-series data of vitals, blood and other laboratory measurements from the previous 7 days. Three different models were assessed by using time series with: 1) most recent patient measurements, 2) summary statistics of trajectories (min/max/median/first/last/count), and 3) coefficients of fitted cubic splines to trajectories. AUROC and AUPRC with cross-validation were used to compare models. We found that the second and third models performed statistically significantly better than the first model. Model interpretations are provided at patient-specific level to inform resource allocation and patient care.


Subject(s)
COVID-19 , Critical Care , Hospitalization , Humans , Machine Learning , Time Factors
16.
East. Mediterr. health j ; 28(3): 175-182, 2022-03.
Article in English | WHOIRIS | ID: gwh-368762

ABSTRACT

Background: Clinical features of confirmed COVID-19 cases cover a wide spectrum. Aims: To study the clinical, radiological and virological features of the first 150 patients with COVID-19 in Lebanon. Methods: Our university hospital was designated as the primary COVID-19 care centre in Lebanon. Between 21 February 2020, the date of the first confirmed case of COVID-19 in Lebanon, and 3 April 2020, our team treated 150 patients diagnosed with COVID-19. In this prospective descriptive study, we present our experience in treating these patients, specifically the diagnostic criteria, outcome, and demographic, clinical, radiological and biological characteristics. Results: Ninety-five (63.33%) of the patients were male and 55 (36.67%) were female. Most patients (58%) were aged > 50 years, and 8 (5.33%) were healthcare workers. Diagnosis was based on reverse transcription polymerase chain reaction, and patients were classified as mild, moderate or critical. Fifteen (10%) patients had a critical presentation and fever was the most prominent symptom at presentation. One hundred and thirty-eight (92%) patients underwent radiological evaluation. The most common laboratory findings were lymphocytopenia (34.38%), followed by neutropenia (28.13%), but leukocytosis was not prevalent (1.56%). Old age and comorbidity were significant indicators in patient risk stratification. Chest computed tomography was an invaluable method of diagnosis and management. Our radiological findings were consistent with the published literature. Conclusion: Our study underlines the variable presentation of COVID-19, the difference in severity, and the diverse methods of diagnosis. This suggests the need for a tailored approach, taking into consideration the wide spectrum of presentation.


Subject(s)
COVID-19 , Betacoronavirus , Disease Outbreaks , Risk Assessment , Polymerase Chain Reaction , Health Personnel , Critical Care , Comorbidity , Demography
17.
J Infect Public Health ; 16(8): 1230-1235, 2023 Aug.
Article in English | MEDLINE | ID: covidwho-2328075

ABSTRACT

BACKGROUND: Coronavirus disease 2019 (COVID-19)-associated mortality is predominantly due to respiratory failure. However, risk factors and predictive models for disease progression in patients with COVID-19 are not consistent across the globe. In this study, we aimed to assess the risk factors associated with intensive care (ICU) admission and mortality in patients with COVID-19 pneumonia. METHODS: Information was retrieved from the database of all patients admitted with COVID-19 pneumonia between March 2020 and July 2020 at a tertiary care center in Saudi Arabia. The patients' demographic, clinical, laboratory and radiological characteristics were analyzed. RESULTS: Of 1054 patients admitted with PCR proven COVID-19, 254 patients (24%) with radiological evidence of pneumonia were enrolled. The median age was 55, with 25.6% above 65 years and 55.1% males. The comorbidities included hypertension (45%), diabetes (43%), dyslipidemia (24%), solid organ and bone marrow transplantation (14.5%), malignancy (13.4%), ischemic heart disease (10.6%) and chronic kidney disease (9.4%). The mortality rate was 4.7%, and 22.8% were admitted to the ICU. The risk factors for ICU admission were> 65 years of age (RR: 1.74, CI 95%, 1.10-2.74, p = 0.017), diabetes melitus (RR: 1.66, CI 95% 1.06-2.62, p = 0.028), heart failure (RR: 2.51, CI 95%, 1.28-4.93, p = 0.007), respiratory rate> 25 (RR: 2.75, CI 95%, 1.66-4.55, p < 0.001), upper lobe involvement (RR: 1.68, CI 95%, 1.02-2.77, p = 0.043), and C-reactive protein (CRP)> 140 (RR: 1.89, CI 95%, 1.14-3.13, p = 0.013). The risk factors for mortality were> 65 years of age (RR: 5.82, CI 95%, 1.81-18.68, p = 0.003), upper lobe involvement on chest radiography (RR:4.40, CI 95%, 1.22-15.86, p = 0.016), diffuse chest computed tomography changes (RR: 7.36, CI 95%, 2.31-23.46, p < 0.011), ischemic heart disease (RR: 4.20, CI 95%, 1.36-13.04, p = 0.028), chronic kidney disease (RR: 6.85, CI 95%, 2.35-19.90, p < 0.003), cerebrovascular disease (RR:13.61, CI 95%, 5.01-36.96 p < 0.001), respiratory rate> 25 (RR: 3.94, CI 95%, 1.32-11.78 p = 0.023), oxygen saturation< 90% on admission (RR: 12.19, CI 95%, 3.71-40.01, p < 0.001), thrombocytopenia (RR:4.16, CI 95%, 1.37-12.64, p = 0.013), and elevated troponin (RR: 6.20, CI 95%, 1.73-22.24, p = 0.003). CONCLUSIONS: In this study, nearly a quarter of the patients with COVID-19 pneumonia required intensive care. We identified several risk factors associated with ICU admission and mortality that may be useful for predicting, triaging, and managing COVID-19 pneumonia patients. However, these findings need to be validated prospectively.


Subject(s)
COVID-19 , Myocardial Ischemia , Pneumonia , Renal Insufficiency, Chronic , Male , Humans , Middle Aged , Female , COVID-19/epidemiology , COVID-19/therapy , Retrospective Studies , Intensive Care Units , Critical Care , Risk Factors
18.
Intensive Care Med ; 49(5): 545-553, 2023 05.
Article in English | MEDLINE | ID: covidwho-2327929

ABSTRACT

PURPOSE: A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients. METHODS: We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days. RESULTS: The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14). CONCLUSIONS: Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States.


Subject(s)
Personnel Staffing and Scheduling , Physicians , Humans , United States , Retrospective Studies , Hospital Mortality , Intensive Care Units , Critical Care
19.
Am J Respir Crit Care Med ; 207(9): 1126-1133, 2023 05 01.
Article in English | MEDLINE | ID: covidwho-2327780

ABSTRACT

The COVID-19 crisis was characterized by a massive need for respiratory support, which has unfortunately not been met globally. This situation mimicked those which gave rise to critical care in the past. Since the polio epidemic in the 50's, the technological evolution of respiratory support has enabled health professionals to save the lives of critically-ill patients worldwide every year. However, much of the current innovation work has turned around developing sophisticated, complex, and high-cost standards and approaches whose resilience is still questionable upon facing constrained environments or contexts, as seen in resuscitation work outside intensive care units, during pandemics, or in low-income countries. Ventilatory support is an essential life-saving tool for patients with respiratory distress. It requires an oxygen source combined to a ventilatory assistance device, an adequate monitoring system, and properly trained caregivers to operate it. Each of these elements can be subject to critical constraints, which we can no longer ignore. The innovation process should incorporate them as a prima materia, whilst focusing on the core need of the field using the concept of frugal innovation. Having a universal access to oxygen and respiratory support, irrespective of the context and constraints, necessitates: i) developing cost-effective, energy-efficient, and maintenance-free oxygen generation devices; ii) improving the design of non-invasive respiratory devices (for example, with oxygen saving properties); iii) conceiving fully frugal ventilators and universal monitoring systems; iv) broadening ventilation expertise by developing end-user training programs in ventilator assistance. The frugal innovation approach may give rise to a more resilient and inclusive critical care system. This paradigm shift is essential for the current and future challenges.


Subject(s)
COVID-19 , Humans , COVID-19/epidemiology , Pandemics , Critical Care , Intensive Care Units , Oxygen
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